Person-Based Cognitive Therapy for Distressing Psychosis (Wiley Series in Clinical Psychology)

PERSON-BASED COGNITIVE THERAPY FOR DISTRESSING PSYCHOSIS Paul Chadwick Royal South Hants Hospital, Southampton and University of Southampton

PERSON-BASED COGNITIVE THERAPY FOR DISTRESSING PSYCHOSIS

The Wiley Series in

CLINICAL PSYCHOLOGY Adrian Wells (Series Advisor) Paul Chadwick Alan Carr Martin Herbert Graham C.L. Davey and Adrian Wells (Editors)

Department of Clinical Psychology, University of Manchester, UK Person-Based Cognitive Therapy for Distressing Psychosis Family Therapy: Concepts, Process and Practice, Second Edition Clinical Child Psychology: From Theory to Practice, Third Edition Worry and Its Psychological Disorders: Theory, Assessment and Treatment

Titles published under the series editorship of: J. Mark G. Williams (Series Editor)

School of Psychology, University of Wales, Bangor, UK

Richard G. Moore and Anne Garland

Cognitive Therapy for Chronic and Persistent Depression

Ross G. Menzies and Padmal de Silva (Editors) David Kingdon and Douglas Turkington (Editors)

Obsessive-Compulsive Disorder: Theory, Research and Treatment The Case Study Guide to Cognitive Behaviour Therapy of Psychosis

Hermine L. Graham, Alex Copello, Max J. Birchwood and Kim T. Mueser (Editors)

Substance Misuse in Psychosis: Approaches to Treatment and Service Delivery

Jenny A. Petrak and Barbara Hedge (Editors)

The Trauma of Sexual Assault: Treatment, Prevention and Practice

Gordon J.G. Asmundson, Steven Taylor and Brian J. Cox (Editors) Kees van Heeringen (Editor)

Craig A. White

Steven Taylor

Health Anxiety: Clinical and Research Perspectives on Hypochondriasis and Related Conditions Understanding Suicidal Behaviour: The Suicidal Process Approach to Research, Treatment and Prevention Cognitive Behaviour Therapy for Chronic Medical Problems: A Guide to Assessment and Treatment in Practice Understanding and Treating Panic Disorder: Cognitive-Behavioural Approaches

A list of earlier titles in the series follows the index.

PERSON-BASED COGNITIVE THERAPY FOR DISTRESSING PSYCHOSIS Paul Chadwick Royal South Hants Hospital, Southampton and University of Southampton

Copyright © 2006 John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex PO19 8SQ, England Telephone (⫹44) 1243 779777 Sections of Chapter 7 and Figure 3.1 are reprinted with permission from Cambridge University Press. Email (for orders and customer service enquiries): [email protected] Visit our Home Page on www.wiley.com All Rights Reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning or otherwise, except under the terms of the Copyright, Designs and Patents Act 1988 or under the terms of a licence issued by the Copyright Licensing Agency Ltd, 90 Tottenham Court Road, London W1T 4LP, UK, without the permission in writing of the Publisher. Requests to the Publisher should be addressed to the Permissions Department, John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex PO19 8SQ, England, or emailed to [email protected], or faxed to (⫹44) 1243 770620. Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The Publisher is not associated with any product or vendor mentioned in this book. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold on the understanding that the Publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought. Other Wiley Editorial Offi ces John Wiley & Sons Inc., 111 River Street, Hoboken, NJ 07030, USA Jossey-Bass, 989 Market Street, San Francisco, CA 94103-1741, USA Wiley-VCH Verlag GmbH, Boschstr. 12, D-69469 Weinheim, Germany John Wiley & Sons Australia Ltd, 42 McDougall Street, Milton, Queensland 4064, Australia John Wiley & Sons (Asia) Pte Ltd, 2 Clementi Loop #02-01, Jin Xing Distripark, Singapore 129809 John Wiley & Sons Canada Ltd, 22 Worcester Road, Etobicoke, Ontario, Canada M9W 1L1 Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books. Library of Congress Cataloging-in-Publication Data Chadwick, Paul (Paul D.) Person-based cognitive therapy for distressing psychosis / Paul Chadwick. p. cm. – (Wiley series in clinical psychology) Includes bibliographical references and index. ISBN-13: 978-0-470-01931-3 (cloth) ISBN-10: 0-470-01931-X (cloth) ISBN-13: 978-0-470-01932-0 (pbk. : alk. paper) ISBN-10: 0-470-01932-8 (pbk. : alk. paper) 1. Cognitive therapy. 2. Psychoses–Treatment. I. Title. II. Series. RC489.C63C532 2006 616.89’142–dc22 2006004514 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library ISBN- 13 978-0-470-01931-3 (ppc) 978-0-470-01932-0 (pbk) ISBN –10 0-470-01931-X (ppc) 0-470-01932-8 (pbk) Typeset in 10/12pt Palatino by Thomson Press (India) Limited, New Delhi Printed and bound in Great Britain by TJ International, Padstow, Cornwall This book is printed on acid-free paper responsibly manufactured from sustainable forestry in which at least two trees are planted for each one used for paper production.

To mum and dad

CONTENTS

About the Author

....................................

ix

Acknowledgements

....................................

xi

Chapter 1 Person-Based Cognitive Therapy (PBCT) for Psychosis . . . . . . . . . . . . . . . . .

1

Chapter 2 Relationship Building, Therapist Assumptions and Radical Collaboration . . . . . . . . . . . . . . . . . . . . . . . .

20

Chapter 3 Framework for PBCT: The Zone of Proximal Development . . . . . . . . . . . . . . .

37

Chapter 4

Working with Symptomatic Meaning . . .

58

Chapter 5 Relationship to Internal Experience: Mindfulness Practice . . . . . . . . . . . . . . . . .

78

Chapter 6

Working with Schemata . . . . . . . . . . . . . .

98

Chapter 7

Self-Acceptance and the Symbolic Self . . 117

Chapter 8 PBCT Groups: Principles and Practice . . 138 Chapter 9

Ending and the Process of Change . . . . . 157

Appendix

BAVQ–R . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174

References

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177

Index

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183

ABOUT THE AUTHOR

Professor Paul Chadwick, PhD, is Head of Clinical Psychology at the Royal South Hants Hospital, and Professor of Clinical Psychology at the University of Southampton. He has an international reputation for his ground-breaking, applied research over the past 20 years on cognitive therapy for psychosis and is lead author on an influential book written with M.J. Birchwood and P. Trower – Cognitive Therapy for Delusions, Voices and Paranoia, also published by John Wiley and Sons.

ACKNOWLEDGEMENTS

One of the true pleasures of writing this book has been to realise just how many people have supported me professionally over the past decade. Writing this book has itself been a process of social and collaborative proximal development. I am indebted to the many colleagues who have supported the development of Person-Based Cognitive Therapy – especially Katie Ashcroft, Laura Dannahy, Ellie Davies, Lyn Ellett, Simon Jakes, Jo Mackenzie, Christina Morberg-Pain, Katherine Newman Taylor, Radu Teodorescu and Clare Williams. Also, thanks go to Sue Williams for her tireless help preparing the manuscript, and to the many teachers of meditation who have supported me since 1996, especially Christina Feldman and all the teachers and managers at Gaia House. I am especially indebted to Nicola Abba for her constant support and encouragement over the years and to Val for her altruistic and constant commitment to this book. Without them all, or the clients with whom I have worked, I could not have written this book. All client names are pseudonyms – indeed, certain details are changed to further protect anonymity – and all client-related materials (therapist and client formulation letters, client writing about therapy and therapy transcripts) are used with permission.

Chapter 1

PERSON-BASED COGNITIVE THERAPY (PBCT) FOR PSYCHOSIS

COGNITIVE THERAPY FOR DELUSIONS, VOICES AND PARANOIA The mid-1980s to the mid-1990s was an inspiring and exciting decade to be working with people with psychosis. Leading psychologists in the United Kingdom such as Richard Bentall, Philippa Garety and Mary Boyle were beginning to subject psychosis to conceptual and experimental scrutiny, and there was a feeling of change – even revolution – in the air. In 1996 we summarised our own contribution over this decade in a book called Cognitive Therapy for Delusions, Voices and Paranoia (Chadwick, Birchwood & Trower, 1996). In that book we presented a cognitive therapy (CT) approach to understanding and alleviating distress associated with those leading positive symptoms of psychosis mentioned in the book title. This approach had eight defining characteristics, which are summarised briefly in the following subsections.

From Syndromes to Symptoms Our work was not based in an illness model. We stated categorically that a medical, syndrome-based model was not a useful foundation for attempts to develop psychological understanding and intervention for psychosis. Based on key texts by Bentall (1990) and Boyle (1990), we rejected the concept of schizophrenia as invalid: ‘It is our view that the major impediment to clinical cognitive approaches in this area has been the very concept of schizophrenia itself … psychiatry traditionally ignores or dismisses as irrelevant much that from a psychological perspective is of central importance’ (p. xiv). In its place we adopted a symptom-based approach (see Bentall, Jackson & Pilgrim, 1988), and structured the conceptualisation of delusions, voices and paranoia around one cognitive framework, the ABC model (see below).

2 PERSON-BASED COGNITIVE THERAPY FOR DISTRESSING PSYCHOSIS

Continuity Not Discontinuity Psychiatry has traditionally stressed discontinuity between on the one hand, psychosis, and on the other hand, affective disorders and ordinary experience. We were inspired by and adopted Strauss’s (1969) conceptualisation that delusions and voices lay on continua with normal behaviour. This position encouraged theorists and therapists working with psychosis to draw on and apply existing psychological and clinical models. As Chadwick et al. (1996) stated: ‘A key feature of our work on these symptoms has been an assumption of continuity between psychotic and nonpsychotic phenomena … one of the main achievements of the cognitive approach to symptoms has been to reveal how the assumption of discontinuity between ordinary experience and psychotic experience was imaginary – there is considerable commonality between delusions and strongly held beliefs, and what differences exist are often subtle and represent variation on common themes. To this extent our cognitive approach may be described as seeking to normalise an individual’s experience’ (p. 176, original emphases, see Kingdon & Turkington, 1994). This shift from discontinuity towards continuity has been supported in research over the past decade, and, indeed, in changes to diagnostic descriptions of psychosis from DSM III to DSM IV.

Cognitive Therapy Targets Client Distress We in fact moved even further away from a medical approach when we asserted that the focus of therapy was not symptoms, but distress. We were the first CT authors to apply this perspective to psychosis. We see this focus on distress as arguably the single most important contribution of the book. So central was this position to our understanding that we defined clinical problems in terms of distress and linked behaviour, and made this the first principle of our cognitive model (pp. 4–5). We stated: ‘This definition of problems in terms of distress and disturbance is, we believe, one of the greatest strengths of the cognitive model. What most clients have been told by other professionals is that they do have a problem – it is their symptoms’ (p. 47). We also stated explicitly a corollary of this position, namely that if a person is not distressed or disturbed by a symptom of psychosis, then this is not a problem and there is no rationale for CT. Our perspective that symptoms were problems only if they distressed or disturbed clients provided the rationale for therapy, and for collaboration – that therapist and client would work together to understand and alleviate the latter’s distress: ‘the cognitive therapist has to convey that her interest is in the client’s emotional and behavioural problems … cognitive therapy is a collaborative process and presumes a common focus

PBCT FOR PSYCHOSIS

3

for change – emotion and behaviour’ (p. 47). Again, we stated: ‘the reason for ever questioning and testing beliefs in a collaborative way is to ease distress and disturbance’ (p. 116).

Commitment to a Cognitive Mediational Model of Distress The defining attribute of CT is a commitment to a mediational understanding of distress (Brewin, 1988) – that is, a premise that people are distressed not by events, but by the meaning they construct. In keeping with this central tenet, we argued that distress was not a direct consequence of psychotic symptoms, but was mediated by meaning given to these symptoms. To represent this we used Ellis’s (1962) ABC framework to formulate people’s experience of voices, paranoia and other symptomatic beliefs. The ABC framework is a general CT tool, not specific to Ellis’s Rational Emotive Behaviour Therapy (REBT) – the components are identical to those included in Beckian analyses of current distress. We chose the ABC framework because it most clearly embodies a focus on distress as the therapeutic focus, and the mediational role of cognition in driving distress (the B sits between the A and C). Table 1.1 shows examples of ABC analyses of a range of symptoms from the 1996 book, which all came direct from clients with whom I was working at that time. Developing a cognitive mediational model for voices was less straightforward than with symptomatic beliefs. The breakthrough was the insight that voices are not cognitions (Bs), but sensations or events (As) within the ABC framework. As we stated: ‘This manoeuvre has a profound impact upon the psychological understanding of voices because it makes clear that distress and coping behaviour are consequences not of the hallucination itself, but the individual’s beliefs about the hallucination … Four types of belief are particularly important in understanding emotional response to voices; those about the voice’s identity, purpose (is it trying to harm or help me?), omnipotence, and beliefs about the consequences of obedience and disobedience’ (1996, pp. 19–20). We used the ABC framework to formulate delusions and voices because it was a model for understanding distress, and linked behaviour, and because it embodied absolutely clearly that distress was the target for therapeutic change.

Linking Delusions, Schemata and Distress In a seminal contribution to the understanding of delusions, Maher and Ross (1984) and Maher (1988) conceptualised delusions as reactions to and attempts to make sense of experience. That is, delusions might be viewed

4 PERSON-BASED COGNITIVE THERAPY FOR DISTRESSING PSYCHOSIS

Table 1.1 ABC analysis of ‘delusions’ and voices Activating event (sensation)

Beliefs (client’s thoughts, images, beliefs)

Consequences (distress and linked behaviour)

Mind reading

Client cannot find a word, therapist supplies it

She’s read my mind, I’ve found her out, I knew it

Elated Pressure to tell people

Paranoid

Car horn sounds outside house

They have come for me, to kill me

Fear Runs from flat

Reference

Doctor walks past window, head held high

He thinks he’s better than me, he’s letting me know

Shame Moves away from window

Grandiose

The queen says on TV she loves all her children

She means me, she loves me, I am her daughter

Elation

Voices

Richard hears a voice say ‘hit him’

It is God testing my strength and faith

Does not comply Feels pleased

Voices

Jenny hears a voice say ‘be careful’

It is the devil, he is watching, waiting to get me

Terror Avoids going to shops

Symptom

Source:

Chadwick et al. (1996).

as expressions of the human necessity to ‘search for meaning’, often in response to life experience that was painful, unusual or ambiguous. This insight formed the basis for our reformulation of delusions in cognitive therapy (see Chapter 4). In particular, we conceptualised delusions as inferences about how the world is – that is, as beliefs which in everyday speech might be called either true or false, thereby encouraging therapists to question the assumption of falsity current in psychiatric thinking about delusions at that time. Viewing delusions as causal inferences helped establish how they linked to distress and schemata (or what we then called person evaluations). Linking delusions and self-esteem was a key challenge at that time (Alford & Beck, 1994). Basing our position in established cognitive theory and research showing how distress reflected a combination of inferential and schematic/evaluative thinking, we argued that when delusions were associated with distress, this must reflect not only delusional inferences, but also underlying negative schematic/evaluative meaning. We gave case examples of how to downward arrow from delusions to these unconditional schemata – a procedure that has since been empirically demonstrated in research (Close & Garety, 1998).

PBCT FOR PSYCHOSIS

5

All People Inhabit a World of Appearances Our cognitive therapy was explicitly constructivist in its philosophical position on access to reality. We adhered to the Kantian view that it is impossible to say anything authoritative about the world as it really is. All any of us is in touch with is the world of appearances, that is, the world as we construct it through our sensory, perceptual and cognitive apparatus. In other words, Kant argued that all perception and knowledge was sense-dependent and mind-dependent. As we stated: ‘In order for an individual to experience anything at all, to be a subject of experience, he or she must possess sensory, intellectual and cognitive capacities of one kind or another. In order for an object to be experienced, it must fit in with these predispositions – individuals can experience no other kinds of objects. It is therefore inevitable that people must always experience a world of appearances, comprising “things as they appeared” to subjects, but could not experience the world in itself’ (p. 7). Kant specified three ways in which people cannot help but construct the world. These are that events be perceived as located in space (space) and occurring in temporal sequence (time), and that they be perceived as orderly and predictable (causality). While these properties specify the basic forms of any possible world of appearances, they cannot be assumed to exist in the world as it really is. We all have to operate in the world of appearances, with a mind that has to simplify a bewildering array of sensory stimuli into a subjectively manageable and coherent flow of experience. Perception both gives coherence and meaning to sensations, and also regulates focus of attention. It is not that in generating meaning or selectively attending people do anything wrong, nor is their thinking faulty or irrational. Indeed, absolute ‘truth–falsity’ is not a valid construct to apply to meaning, precisely because people live in a world of appearances.

Primacy of the Therapeutic Relationship We were explicit that the practice of CT occurred within a sound, person-centred relationship: ‘There are at least two important prerequisites to the practice of effective cognitive psychotherapy. The first is the use of good basic counselling skills in order to (i) Establish a good working alliance, (ii) Engage the person fully in collaborative empiricism (Beck, Rush, Shaw & Emery, 1979), (iii) Understand the client’s unique perspective and feelings, (iv) Help the client carry out the difficult and often painful work of therapeutic change … The second prerequisite is a sound knowledge of the principles of cognitive formulation and intervention and the use of a cognitive framework’ (Chadwick et al., 1996, pp. 25–26).

6 PERSON-BASED COGNITIVE THERAPY FOR DISTRESSING PSYCHOSIS

Therapy as a Conceptual Process A further defining feature of our approach was to present CT for psychosis as a clear conceptual process, with clearly delineated conceptual steps, rather than a manual of techniques: ‘what we are proposing is a sequence of conceptual steps, not a sequence of technical ones’ (p. 27). There were two main reasons for this. First, a technical manual is, in our view, insufficiently collaborative or person centred. Second, when working to a technical sequence, therapists struggle when therapy does not go according to plan.

THE NEED FOR A PERSON-BASED APPROACH TO PSYCHOSIS We concluded our 1996 book suggesting that the psychology of psychosis had undergone a productive paradigm shift away from a syndrome model to a symptom model: ‘the move away from studying schizophrenia as a syndrome, towards studying individual symptoms, liberated and energised psychological research and practice’ (p. 179). This change occurred in part because of major scientific questions over the validity of the concept of schizophrenia (see Chadwick et al., 1996, pp. xiii–xviii ) – concerns which persist to this day. We concluded by arguing that the time was right for a further shift away from a symptom model towards a person model. The reasons offered for this call were that the symptom model was essentially a transitional model. It faced some key challenges. For example, if a person’s specific symptom – a voice, a grandiose delusion or a persecutory delusion – disappeared, what vulnerability remained? We could see no compelling, empirically established theory for the emergence of individual symptoms of psychosis. Indeed, it seemed clear that there were multiple pathways to each symptom. Also, people invariably presented with more than one symptom – was a separate theory needed to account for each? And this was to say nothing about clients’ (often preexisting) anxiety, depression, negative self schemata (NSS), and so on. We thus concluded: ‘symptom based work may be seen as signifying more a rejection of syndromes than itself being a viable comprehensive psychological approach to clinical problems’ (Chadwick et al., 1996, p. 180). The challenge was to develop a broader, person-based context, within which symptom work would remain an important element. In 1996 we did not have a clear picture of what a person-based approach would be, but rather were sharing our aspirations at that time, hoping to provide a springboard for future developments. Looking back, what is apparent is that the call was for a context that was not solely theoretical, but also was fundamentally a framework for therapy. In other words, a personbased approach would supply an overarching, theoretical and therapeutic

PBCT FOR PSYCHOSIS

7

context. Working with symptomatic distress would then assume an important place within this context, alongside an emphasis on therapeutic relationship and processes of change, on distress associated with schemata (i.e. non-psychotic sources of distress) and a person’s strengths and potentialities. When calling for a person model, it was not being argued that the symptom-based developments in CT were becoming obsolete. The symptom-based work we described in 1996 remains relevant and useful to clinicians today. PBCT retains as a central focus working with distress linked to symptomatic meaning. It offers a psychological approach to understanding and alleviating distress, not symptoms, and holds true to all eight distinguishing features of our 1996 approach.

PERSON-BASED COGNITIVE THERAPY (PBCT) FOR PSYCHOSIS Fundamentally the person model presented in this book is an overarching framework for therapy that places the person – including all sources of distress, and positive strengths – at the heart of the process. Moving from a symptom model to a person-based model has necessitated five substantial developments. Each is introduced in this section, and subsequently examined in detail in its own chapter. First, PBCT picks up and elaborates substantially the earlier focus on the therapeutic relationship in general, and in particular on the way in which therapist beliefs threaten relationship building (‘engagement’). Second, it presents a new organising framework for therapy developed out of Vygotsky’s (1978) concept of a Zone of Proximal Development (ZoPD). Third, mindfulness assumes a key role in PBCT. Conceptually, mindfulness shows how distress arises from relationship with experience, as well as from meaning, and practically, mindfulness meditation becomes an important intervention to alleviate distress and promote well-being. Fourth, there is substantial development of work on the self – the concept we identified in 1996 (p. 182) as a building block for a person model. Fifth, metacognition assumes an important place both in conceptualising distress and articulating processes of change.

The Therapeutic Relationship in PBCT: Radical Collaboration I feel deep concern that the developing behavioural sciences may be used to control the individual and to rob him of his personhood. I believe, however, that these sciences might be used to enhance the person. (Rogers, 1961, p. 362)

It has continued to surprise me over the past decade how people reading CT texts, including our 1996 book, frequently underestimate the centrality of a person-centred relationship to the process of therapy. Reflection

8 PERSON-BASED COGNITIVE THERAPY FOR DISTRESSING PSYCHOSIS

on this has led me to conclude that we (and perhaps other CBT (cognitive behaviour therapy) writers) devoted insufficient space in our writing to spelling out the ramifications of being person centred in all areas of therapeutic practice. It is clearly insufficient to state that the relationship needs to be Rogerian – what does this mean in CT terms, and what are the main threats to this type of relationship occurring in therapy with people with distressing psychosis? In response to this point, in this book the very choice of title, PersonBased Cognitive Therapy, stresses the centrality of a Rogerian foundation. Also, Chapter 2 is devoted solely to the therapeutic relationship. It takes an explicitly cognitive perspective, and argues that therapists’ own beliefs and assumptions about how therapy should progress pose the greatest threat to relationship building. Chapter 2 introduces a term – radical collaboration – to capture a mode of therapy that occurs when therapists are free of anti-collaborative assumptions about how therapy should progress and what should be achieved. Positive assumptions are described that support radical collaboration in practice. PBCT is grounded in Rogerian acceptance. Radical collaboration is a CT-based expression of Rogerian acceptance. Acceptance flows through all aspects of PBCT. Rogers (1961) says acceptance means ‘that the therapist feels this client to be a person of unconditional self-worth: of value no matter what his condition, his behaviour or his feelings’ (p. 185). Acceptance means accepting the ‘feelings and attitudes and beliefs that he has as a real and vital part of him’ and is based on ‘the right of each individual to utilize his experience in his own way and discover his own meanings in it – this is one of the most priceless potentialities of life’ (p. 21). In a therapeutic context, Rogerian acceptance has several properties: (1) Acceptance is unconditional. That is, therapists are open to and accept all aspects of the client, including the difficult and challenging. As Rogers asks, ‘Can I really permit another person to feel hostile towards me? Can I accept his anger as a real and legitimate part of himself? Can I accept him when he views life and its problems in a way quite different from mine?’ (1961, p. 20). (2) Acceptance is possible only if therapists replace judgement and evaluation with understanding: ‘Our first reaction to most of the statements we hear from other people is an immediate evaluation or judgment, rather than understanding it’ (p. 18). (3) Therapist acceptance of clients facilitates clients’ self-acceptance: ‘my understanding … permits them to accept their own fears and bizarre thoughts and tragic feelings and discouragements, as well as their moments of courage and kindness and love and sensitivity’ (p. 19). (4) Acceptance is not only of persons’ present experience, but also of their right to choose the direction in which they change (p. 109).

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It is something of a relief to read Rogers’ statement that maintaining acceptance is ‘by no means an easy thing’ (1961, p. 21). It is an aspiration, not a demand, and maintaining an accepting attitude is an ongoing process. Therapists need to be self-reflective, seeking to become increasingly aware of their judgements (without then judging themselves for making those judgements) and anti-collaborative assumptions about how therapy should progress. This type of awareness is supported by regular supervision that explicitly examines therapists’ reactions (including judgements) to clients, and by a practice like mindfulness that creates an opportunity for therapists to become more aware and accepting of their own internal experience. Also, therapists’ acceptance of clients is supported by their capacity to accept all aspects of their own experience. Radical collaboration is intended to help therapists to accept themselves and their clients regardless of how therapy progresses, and so to remain consistently person centred and collaborative. There will be times when clients’ behaviour or attitudes will tax a therapist’s capacity for acceptance to the limit. At such times, acceptance can be genuine only when the therapist ‘senses the potentialities of the individual’ (Rogers, 1961, p. 357). This is linked to a fundamental Rogerian assumption – namely, that clients’ core is a potentiality to become themselves fully in ways that are emotionally positive and social (see Chapter 2, Assumption 1). One way of conceptualising the ZoPD is the realisation of this potentiality. PBCT is not based on a simplistic formula, along the lines of ‘the relationship is Rogerian and the specific methods and techniques are cognitive’. Clearly traditional CT also has much to say about therapeutic relationship (see Chapter 2). Also, in reality there is no easy separation between relationship and methods. Central concepts such as collaboration and Socratic dialogue, for example, are both method and relationship.

Zone of Proximal Development: A Conceptual Framework for PBCT When calling in 1996 for a shift from a focus on symptoms to a broader person-based perspective, we were unclear what this framework might be. What has emerged over the past decade is a person model that is both a continuation of the central focus of the 1996 book, but also different. PBCT adapts Vygotsky’s (1978, pp. 84–91) concept of the ZoPD as a central framework for the process of therapy. Traditional case formulation materials are used to support this central framework (see Chapter 3). Vygotsky challenged the prevailing Western approach to assessing child development, which was to assess how well children could perform on a certain test, unaided. Coming from a dialectical understanding of learning and development as a social process, Vygotsky argued for a new method

10

PERSON-BASED COGNITIVE THERAPY FOR DISTRESSING PSYCHOSIS

for assessing child development – namely to also assess what a child might achieve when supported by an adult. He argued that two children showing a comparable level of development when assessed in isolation might show divergent developmental levels if assessed through collaboration with adults. He labelled the space between what a child might achieve alone and with adult help the Zone of Proximal Development. Vygotsky defined the ZoPD as follows: ‘It is the distance between the actual developmental level as determined by independent problem solving and the level of potential development as determined through problem solving under adult guidance or in collaboration with more capable peers’ (p. 86). I have long been interested in the idea that ‘the therapeutic process can be seen to explore the client’s zone of proximal development’ (Chadwick, 1989, p. 28). The analogy is uncomfortable if one equates the parent–child relationship with that between therapist and client – this is not in any way the intention. Rather, the concept of a ZoPD is an exciting framework for conceptualising the process of therapy because it is a dynamic, creative and positive framework, it takes an explicitly developmental perspective on the process of learning and change, and it asserts that emotional and psychological development occurs though a social and collaborative process. I adapt the concept of ZoPD to become the central organising framework in PBCT (see Figure 1.1) comprising four domains of possible proximal

Relationship with internal experience

Symptomatic meaning

Radical collaboration

Radical collaboration

Four domains of proximal development

Radical collaboration

Schemata

Figure 1.1

Radical collaboration

Symbolic self

Four domains of proximal development

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11

emotional and psychological development (a person’s actual ZoPD becomes known only through a collaborative therapeutic process). These represent distinct sources of current distress and disturbed behaviour, and of potential emotional and psychological development. These four domains are symptomatic meaning, relationship, schemata and the symbolic self (addressed in Chapters 4, 5, 6 and 7, respectively). Symptomatic meaning concerns working directly with paranoia, beliefs about voices, and other so-called ‘delusions’. Relationship is addressed using mindfulness meditation. Clients learn to respond mindfully to unpleasant psychotic sensations, letting go of habitual distressing reactions. Schemata concerns easing distress associated with negative schemata of self and others, and developing positive self schemata. Symbolic self concerns an overarching metacognitive understanding of how ‘self’ is a complex changing process, not a fixed entity. I define therapeutic exploration of the ZoPD as follows: a social process, whereby with the support of a radically collaborative and skilled therapist a client eases distress, develops metacognitive insight and achieves selfacceptance through proximal development in all four domains.

Mindfulness A third significant developmental aspect of PBCT is the inclusion of mindfulness theory and practice. The emergence of mindfulness-based interventions has been one of the most exciting developments of psychotherapy over the past decade. Two main interventions are based predominantly around mindfulness practice, Mindfulness-Based Stress Reduction (MBSR; Kabat-Zinn, 1990) and Mindfulness-Based Cognitive Therapy (MBCT; Segal, Williams & Teasdale, 2002b). Also, mindfulness is a key component of Dialectical Behaviour Therapy (Linehan, 1993) and has clear parallels with Acceptance and Commitment Therapy (ACT; Hayes, Strosahl & Wilson, 1999), which has shown promising results with people with psychosis (Bach & Hayes, 2002). I have practised mindfulness meditation since 1996. It is only because I had personally experienced the benefits and challenges of meditation over a sustained period that I felt prepared to introduce it to clients, initially in individual therapy and latterly also in groups. This occurred in an atmosphere of collaborative empiricism (Beck et al., 1979). I was open with clients that this was a new venture, and invited them to work with us to determine if mindfulness might be helpful to people distressed by voices, paranoia or images. Chapter 5 is devoted entirely to the practice and process of learning to relate mindfully to unpleasant psychotic sensations. In this section mindfulness is defined, and then assimilated conceptually into PBCT.

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PERSON-BASED COGNITIVE THERAPY FOR DISTRESSING PSYCHOSIS

What is Mindfulness? 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 … in the Buddhist sense Mindfulness – sati – is always combined with wisdom – panna. (Ajahn Sumedho, 1992, pp. 31–32)

This point is of fundamental importance. Mindfulness as used within PBCT has two main aspects. On the one hand, there is a clear, open and gentle awareness of whatever is present, marked by acceptance and an absence of reaction (avoidance, struggle, rumination, etc.). This is what is practised in formal sitting. On the other hand, there is an explicit focus on reflective learning about the nature of experience. It is often during reflection that important metacognitive insights are made, rather than during the experiential practice itself. These two sides of mindfulness – awareness and understanding – are equally important, and share a dialectical relationship, the one constantly informing and shaping the other. Not for nothing is this form of meditation also called Insight Meditation. Mindfulness practice is most transformative when clients both have moments of decentred awareness of unpleasant psychotic sensations without reacting and draw explicit metacognitive insights about this experience. Integrating Mindfulness and CT Opinion is divided as to whether mindfulness and CT can be integrated within one coherent therapeutic approach. My view is that they can, but only if there is conceptual clarity – and awareness of the ‘wisdom’ aspect of mindfulness. In particular, integration is possible because they share a common premise, a common aim, and seek to impart conceptually similar metacognitive understanding about the sources of distress and the nature of self. The fact that the practice of meditation and CT are different is an advantage, offering diverse yet complementary methods for change. There are solid grounds for integrating mindfulness and CT. Mindfulness and CT define a common focal ‘problem’ – that is, distress/suffering. They share a common aim – to understand and alleviate distress and promote emotional well-being (Cs). Crucially, they share a fundamental assumption about the source of distress – namely that it is not situations or sensations (As) that ‘cause’ distress (C), but the cognitive reaction or mediation (B) to them (Teasdale, Segal & Williams, 1995, p. 38). Also, in both traditions judgement is identified as one such reaction; judgement can be of sensations (a bad thought, voice, etc.), or self (I am bad), or both. Again, both traditions link distress to a human tendency to experience sensations (e.g. a derogatory voice) and self-perceptions (e.g. a negative

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evaluation) as facts, or truths. Lastly, they both seek to impart what Teasdale and colleagues (2002) call metacognitive insight as a key process of change (the wisdom element of mindfulness: see above definition). For example, in mindfulness people learn to decentre from cognitions and perceive them as transient objects of awareness, not indisputable facts or truths that define the self or ‘reality’. In CBT, encouraging clients to recognise that their self-evaluations are beliefs, not facts, has been a first step for many years (Clark, 1989, p. 68; Trower, Casey & Dryden, 1988) along with finding experimental modes in which to move this recognition to the experiential level (Fennell, 1989, p. 200). This integration can be conceptualised in a revised ABC model of distress, shown in Table 1.2. Cognitive mediation includes meaning, those cognitions that have been the backbone of CBT understanding of distress. Cognitive mediation also includes relationship to sensations (experiential avoidance, rumination, judging). Metacognition is common to both a cognitive- and mindfulness-based understanding of distress. Collectively the three drive distress. Meaning and Relationship are Linked What makes the integration of mindfulness and CT so valuable is that within the realm of cognitive mediation, they have emphasised two distinct but functionally linked domains. Where CT has traditionally emphasised meaning triggered by sensations, mindfulness stresses relationship with sensations. Yet meaning and relationship are inextricably linked. There are underlying assumptions, or rules, which though implicit lead clients to relate to unpleasant sensations in distressing ways. This shows the important strategic quality of underlying rules, in that they regulate not only overt behaviour but also internal experience. For example, experiential avoidance is supported by implicit or explicit beliefs such as ‘I cannot tolerate this experience’, ‘If I experience it I will lose control or go mad’, or ‘I can never be happy if I have these kind of experiences’. Rumination on voices and paranoia is supported by cognitions such as ‘Unless I fight and struggle the voice will overpower me’, ‘If I don’t resist,

Table 1.2 Integrating CT and mindfulness within an ABC model of distress Situation (A)

Cognitive mediation (B)

Distress (C)

Situation and specific sensations (pleasant, unpleasant or neutral)

Meaning (CT) Relationship (mindfulness) Metacognition (CT and mindfulness)

Emotional experience Behaviour (urge and action) Bodily experience

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then I am endorsing what the voice says’, or ‘I must work out what is going on, if I am ever to end the persecution’. Judgement is supported by beliefs such as ‘I am what I experience’, ‘Unpleasant sensations are bad or wrong’, ‘Thinking something is the same as doing it’, or ‘Bad people have bad thoughts’. This link explains why the two change in tandem. Segal et al. (2002b) observed how working with meaning in traditional CT had the effect of altering a person’s relationship with sensations/experience (as well as changing the meaning itself, which must not be forgotten). Similarly the process of changing relationship with sensations experientially through mindfulness changes meaning – the person learns transforming metacognitive insights. Were this not so, mindfulness practice, with all its experiential qualities, would have limited value. In PBCT mindfulness practice is intended to ease distress by altering habitual relationships with experience, and by imparting liberating metacognitive insights about psychotic sensations, the self, and the origins of distress and well-being. The view that distress results not from sensations or events but from people’s reactions underpins mindfulness practice and CT. It makes no value judgement about the rightness or wrongness of reactions; it simply locates distress as coming from people’s interactions with sensations, rather than being intrinsic to those sensations. This is empowering for clients because it means that reduction of distress can always be achieved by proximal development within one or more of the four zones. This does not mean that interventions should not also be aimed at society, environment, community, ward, family and so on. These are complementary and not alternative approaches. What the cognitive model and mindfulness assert is that an environment or situation or sensation does not have to produce the same emotion in all people, and that what explains this emotional range is cognitive mediation (meaning and relationship). This freedom not to be determined solely by our environment gives us our humanity.

The Self in PBCT PBCT addresses the challenge of conceptualising and working with the self in three main ways. These are: (1) a unifying premise that the self is a process, (2) working with self schemata and (3) a central goal of self-acceptance. Self as Process Chadwick et al. (1996, chapter 8) join a long tradition within Western psychology for conceptualising the self as a process rather than a fixed

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entity, or object (e.g. Goffman, 1959; Harre, 1979; Maslow, 1954). To view the self as an object or thing is to commit what philosophers call a ‘category mistake’ (G. Ryle, 1949). Ryle illustrates a category mistake by describing an imaginary visitor to a university, who having met the staff and been shown the colleges, departments, libraries and administrative buildings, asks, ‘But where is the university?’ (pp. 17–18). Self is thus not an additional thing that sits alongside a person’s experience; it is a term that signifies a person’s reflexive capacity to describe and identify with aspects of his or her experience. This view of self as process is a unifying premise within PBCT. It is of fundamental importance within Rogers writings: ‘One of the most evident trends in clients is to move toward becoming all of the complexity of one’s changing self in each significant moment’ (Rogers, 1961, p. 172). For this to happen clients need to relinquish constructions that fix and narrow self and thereby create conflict (p. 27). Within mindfulness traditions, and underlying Buddhist psychology, the main source of suffering is precisely an illusory belief that the self is fixed, unchanging and somehow sits outside the world of changing conditioned phenomena (Rahula, 1959). Mindfulness practice is rooted in the central insight that the whole of experience is a changing, interrelated process, in which nothing is fixed. Mindfulness meditation is an experiential process of connecting with the changing nature of experience through moment-to-moment awareness. For Vygotsky (1978) a prime aim was to understand the development of what he called higher psychological functions – those uniquely human attributes which emerge through a complex social developmental process. Vygotsky argued that this aim necessitated a radically new analytical method (pp. 61–65). The first principle of this method was ‘analysing process, not objects’. For Vygotsky, moving from describing higher psychological functions to explaining them necessitated tracing their developmental and social origins, rather than measuring them in their current ‘fossilised’ form. Socially developed higher psychological functions, such as a language-based sense of self, are processes ‘undergoing changes right before one’s eyes’ (p. 61). Positive and Negative Self Schemata From clients’ points of view, one of the most compelling and distressing aspects of the process of self is the experience of negative self schemata (NSS). At the phenomenological level, such experiences ‘fix’ the self and give it the appearance of an entity, object or product. The sense of self as a complex, changing process is lost. In PBCT there is a strong focus on working with NSS (Chapter 6). There is an emphasis on acceptance of negative schematic experience as part of the self, not the self. The importance of

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developing a positive self schemata (PSS; Greenberger & Padesky, 1995) is reflected in our use of two-chair methods for drawing out experientially and consolidating PSS. Our use of two-chair methods is adapted from the important and pioneering work of Greenberg, Rice and Elliott (1993); the methods are emotionally vivid (or ‘lived’) and have clear conceptual aims involving both cognitive and metacognitive change. Chapter 6 also presents two-chair enactments for bringing NSS into balance. Self-Acceptance Third, a central goal of PBCT is to promote self-acceptance. For clients, self-acceptance means, among other things, accepting unpleasant psychotic sensations without struggling against them or defining themselves in terms of these experiences. This emphasis on self-acceptance comes chiefly from the work of Rogers and mindfulness traditions. Self-acceptance means opening awareness to accept all aspects of experience without judgement or struggle (e.g. thought suppression). Rogers’ presentation of self-acceptance is remarkably consistent within mindfulness practice: ‘One aspect of the process of therapy which is evident in all cases might be termed the awareness of experience, or even the “experiencing of experience” … In the security of the relationship with a client-centred therapist … the client can let himself examine various aspects of his experience as they actually feel to him, as they are apprehended through his sensory and visceral equipment, without distorting them to fit the existing concept of self’ (Rogers, 1961, p. 76). It is this process of opening awareness to all aspects of the self which directly supports selfacceptance. As Rogers (1961) stated, ‘one of the most evident trends in clients is to move toward becoming all of the complexity of one’s changing self in each significant moment’ (p. 172) thereby ‘getting acquainted with each piece of the self’ (p. 78). This metacognitive understanding of self as complex, contradictory and changing is represented in PBCT with the concept of symbolic self. Symbolic self is a term introduced by Sedikides and Skowronski (1997) and is defined as a person’s ‘abstract cognitive representation of itself through language’. It includes diverse experiences of self that may not be well integrated with one another, and can be contradictory (Sedikides & Skowronski, 1997) – such as positive and negative self-schematic experience. It is widely recognised within social psychology that people have numerous possible selves (Markus, 1977). Within PBCT the symbolic self is conceptualised as a metacognitive understanding of self that comes from decentred awareness and acceptance of a changing, diverse and contradictory range of experience. It is this metacognitive understanding that facilitates acceptance of negative self-schematic experience as one type of emotionally charged experience of self, but one that can never define the self (see Chapter 7).

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Metacognition The fifth main development in moving towards a person model is the emergence of metacognition as a key concept. Therapists from different schools have recognised the therapeutic potential of clients being able to take a metacognitive perspective on internal experience (e.g. Rice & Greenberg, 1984). In relation to CT, Ingram and Hollon (1986) state ‘cognitive therapy relies heavily on helping individuals switch to a controlled mode of processing that is metacognitive in nature and focuses on depression related cognition’ (p. 272). The central importance of metacognition within cognitive theory and therapy has been established by important work from, among others, Wells on anxiety (Wells, 1997; Wells & Matthews, 1994), Morrison, Wells and colleagues on psychosis (Morrison & Wells, 2003; Morrison, Wells & Nothard, 2000) and Teasdale and colleagues on depression (1995, 2002). Defining Metacognition Metacognition can feel a somewhat hazy concept. Authors use it to mean different things, and also use it in compound phrases (metacognitive awareness, metacognitive knowledge, etc.), which further strains clarity. In the following section, I discuss two key influences – Flavell and Teasdale – and then set out as plainly as possible how the term metacognition is used within PBCT. In a landmark paper, Flavell (1979) defined metacognition as ‘knowledge and cognition about cognitive phenomena’ (p. 906). Flavell separated metacognitive knowledge and experience. The former he defined as ‘knowledge or beliefs about what factors or variables act and interact in what ways to affect the course and outcome of cognitive enterprises’ (p. 907) and the latter as ‘any conscious cognitive or affective experiences that accompany and pertain to any intellectual enterprise’ (p. 906). In fact, these two types of metacognition are not distinct, but ‘partially overlapping sets’ (p. 908). In an influential contribution, Teasdale and colleagues offer a related distinction between metacognitive knowledge and metacognitive awareness. Metacognitive awareness is defined as ‘the process of experiencing negative thoughts and feelings within a decentred perspective’ (2002, p. 276), and ‘refers to the extent to which thoughts, for example, are experienced as thoughts (mental events) rather than as aspects of the self or direct reflections of truth’ (p. 277). On the comparison of metacognitive knowledge and awareness, they say: ‘Metacognitive knowledge refers to beliefs about cognitive phenomena stored in memory as propositional facts in much the same way as other facts … metacognitive insight (awareness) refers to actually experiencing thoughts as thoughts (that is, as

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events in the mind rather than direct readouts on reality) in the moment they occur. By contrast, metacognitive knowledge involves thinking about thoughts as “other than facts” or knowing, intellectually, that the content of thoughts does not always correspond to the state of the world’ (p. 286). This analysis has one significant difficulty – I find it conceptually confusing to label awareness as metacognitive. I therefore separate the concept of decentred awareness from that of metacognition. This yields the following definitions: • Decentred awareness. Safran and Segal (1996, p. 117) describe the concept of decentring as ‘a process through which one is able to step outside of one’s immediate experience, thereby changing the very nature of that experience’. Teasdale et al. (2002) describe it as follows: ‘rather than simply being their emotions, or identifying personally with negative thoughts and feelings, patients relate to negative experiences as mental events in a wider context or field of awareness’ (p. 276). However, crucially, in PBCT decentred awareness is not labelled metacognitive. The fact of decentring from cognitions does not make awareness metacognitive, it is simply decentred awareness of cognitions – indeed, awareness. • Metacognitive insight. Metacognitive insight is defined as an observation about a general quality of sensations, cognitions, emotions or the relationships among them. I have used plurals intentionally. If one says of a thought ‘that didn’t last long’ this does not qualify for a metacognitive insight, it is simply an observation about a specific thought. If one says ‘thoughts are transient’, then this is a clear metacognitive insight. Again, if one says ‘this thought depressed me’, this is simply an observation about a specific cognition–emotion link. If one says ‘thoughts about loss lower mood’, this is a metacognitive insight because it observes a general relationship between cognition and emotion. Separating decentred awareness from metacognitive insight has advantages. First, it clarifies that it is quite possible – even common – for people to have moments of decentred awareness of cognitions and other sensations without metacognitive insights ensuing. Metacognitive insights are examples of language-based proximal development which may or may not be realised. This explains why mindfulness-based therapies explicitly work to support metacognitive insight – it does not follow necessarily from decentred awareness. Second, it clarifies that metacognitive insight need not occur only during moments of decentred awareness of thoughts, voices or images (as Teasdale and colleagues appear to assert) but equally can occur later during reflective learning. Third, it is this separation of metacognitive insight and decentred awareness that is crucial to an integration of mindfulness-based therapies and CT, because both are seeking to foster comparable metacognitive insights.

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Like all classes of cognition, metacognition can be a source of distress or emotional well-being. In this volume we have referred to those metacognitions that drive distress as metacognitive beliefs. Examples of metacognitive beliefs are ‘only bad people have bad thoughts’, ‘I ought to be able to control my thoughts’, and ‘paranoia keeps me safe’. In contrast, metacognitive insights support emotional well-being. Examples are ‘having unpleasant thoughts is universal so cannot define a person’ and ‘in those moments when voices are accepted, they cease to be distressing’. Within this taxonomy, researchers seek to show how metacognitive beliefs are involved in the maintenance of distress; therapists seek to develop interventions intended to promote metacognitive insight. The Place of Metacognition in PBCT The process of exploring a person’s ZoPD involves promoting metacognitive understanding in all four domains. We have seen already in this chapter how the concept of metacognition is inextricably linked with the practice and aims of mindfulness. So, too, metacognitive insight is inextricably linked with the concept of symbolic self, which is an expression of metacognitive insight that the self is a complex, contradictory and changing process. Gaining metacognitive insight about the nature of negative self schemata, and their impact, is an important aim of two-chair methods (Chapter 6). In relation to symptomatic meaning, looking back it is clear how our cognitive therapy for symptoms of psychosis (Chadwick et al., 1996) included key metacognitive interventions (see Chapter 4, this volume). That is, we described interventions for working with symptomatic meaning that had an explicit aim of communicating understanding about cognitive processes, rather than weakening conviction in a particular belief.

CONCLUSION In summary, PBCT is an approach to understanding and alleviating distress and linked behavioural disturbance, and moving towards emotional well-being and self-acceptance. It is an integration of CT for psychosis, mindfulness and Rogerian person-centred counselling. It has a clear organising framework for therapy, developed out of Vygotsky’s concept of a Zone of Proximal Development. It describes a collaborative therapeutic process developed to alleviate four sources of distress and build on strengths in each domain, in a conceptually and practically coherent way that remains person based throughout.

Chapter 2

RELATIONSHIP BUILDING, THERAPIST ASSUMPTIONS AND RADICAL COLLABORATION

OVERVIEW This chapter covers the therapeutic relationship in PBCT. It begins with a brief review of the therapeutic relationship in traditional cognitive behavioural therapy (CBT), and then focuses in on the issue of engagement – or what I prefer to call relationship building. Therapists’ anti-collaborative assumptions are isolated as the major threat to relationship building, and this leads to a discussion of the type of relationship that occurs in PBCT, radical collaboration. Radical collaboration is defined as a relationship that is free from the influence of therapist anti-collaborative assumptions. Finally, some key positive assumptions that support radical collaboration are presented.

RELATIONSHIP BUILDING The basic ingredients of a CBT relationship are, in fact, common to all talking therapies – that is, ‘warmth, empathy, caring, genuine regard and competence’ (J. Beck, 1995, p. 5). Lazarus (1992) rebuts what he calls the prevalent ‘myth’ that this generic therapeutic relationship is usually both necessary and sufficient to produce significant change. Change is most likely to occur, Lazarus argues, when this type of relationship is supplemented with a competent and flexible application of tried and empirically tested methods. Power and Brewin (1997), in a comprehensive analysis of different psychotherapeutic approaches, reach the same conclusion. Blackburn and Twaddle (1996) offer a clear and concise summary of these technical attributes of CBT. They say that CBT is characterised by (1) the centrality of the cognitive conceptualisation, (2) a phenomenological emphasis, (3) the collaborative nature of the relationship, (4) active involvement of the patient, (5) the use of Socratic questioning and guided discovery, (6) explicitness of the therapist, (7) an emphasis on empiricism

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and (8) an outward focus (i.e. promoting generalisation of change to the outside world by tasks such as homework). There is also agreement that as CBT is applied to clients with more complex problems, the therapeutic relationship assumes greater importance. With CBT for psychosis in particular, writers repeatedly comment on how a traditional approach to relationship building falls short. In our earlier book, we isolated relationship building as the single biggest challenge facing a therapist (Chadwick et al., 1996). The concern over engagement is that many clients never get to experience a potentially helpful therapy.

THREATS TO RELATIONSHIP BUILDING: ANTI-COLLABORATIVE MODES Traditionally engagement refers to the degree to which a client commits to therapy; it does not refer to therapeutic outcomes. Therapists use methods specifically intended to engage clients; for example, showing knowledge of the phenomenology of voice hearing, by occasional second guessing (Chadwick et al., 1996, chapter 5). For reasons that will become apparent, in PBCT the phrase relationship building is used instead of engagement. Relationship building is the degree to which therapist and client feel they share an open and collaborative relationship. It is an interpersonal process, within which therapist and client might have differing perceptions. Chadwick et al. (1996, chapter 2) isolated several threats to relationship building: (1) therapist failure in empathy, (2) therapist beliefs, (3) client beliefs (which include seeing no potential gain), (4) relating to a therapist being too anxiety provoking and (5) two specific steps in the process of CT which require considerable therapist sensitivity (clarifying that ‘delusions’ are beliefs, not facts, and establishing a rationale for examining them – which is that they drive distress and disturbance). Over the ensuing decade I have come to suspect that the greatest of these threats is therapist beliefs and assumptions – what I now call anti-collaborative modes. Therapists themselves often feel anxious in the early stages of work. This anxiety, as the CT model asserts, results from implicit assumptions and beliefs therapists hold about how therapy should progress. Table 2.1 lists four therapist anti-collaborative modes that threaten relationship building and drive therapist anxiety. Each mode contains cognitions, emotions and behavioural urges around a particular theme. All modes are played out interpersonally with clients, potentially developing vicious cycles. A therapist who is becoming frustrated by a lack of change and becomes more strident in belief challenging, for example, is likely to evoke psychological reactance (Brehm, 1962) in the client – which works directly against belief change. The first class of belief is really surprisingly common, and interacts with the others. Anticipatory failure is defined in a principal rule or

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Table 2.1 Common therapist beliefs, feelings and behaviours which threaten collaborative working in CBT for psychosis Failure

Risk to self

Risk to client

Organisational beliefs

Belief 1

It is my People with responsibility psychosis are to keep the dangerous person in therapy

Belief 2

I might lead There’s no point I’ll become the person in therapy if part of the to suicide the patient delusion, doesn’t which is a bad change and dangerous thing

Belief 3

I’m no good if I can’t achieve this thing

People with psychosis are unpredictable, therapy is unsafe

Colleagues will Clients are think badly unable of me if I say to take no decisions: I must keep them safe

Belief 4

I don’t know how to do this work

I’ll use the wrong words and anger the person

Therapy I’m responsible must for this never be person’s welldistressing being

Belief 5

In order for me to be a competent therapist, clients must always change: I should get change

People with psychosis cannot form collaborative relationships

I should be I don’t have the able to right to say stop clients no or ask that attempting I be properly suicide supervised

Feelings

Anxiety, frustration, helplessness, hopelessness

Anxiety, fear

Anxiety

Stress, anxiety, frustration

Avoidance, ’pussy foot’

Controlling, overcautious, superficial

Get out of one’s depth

Behaviour Be controlling, push hard, self-focused attention

I might upset Someone must or distress offer CBT for the person psychosis

If I don’t do it, no one will

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assumption: ‘In order for me to be a worthwhile therapist (or even person), clients must remain in therapy and change’. Therapists operating in this mode feel discomfort or low-level anxiety, experience negative automatic thoughts (NATs) about incompetence, are likely to be controlling, attentive to change-related cues and their own NATs, and strive to meet their own needs. If clients do not change, therapists’ frustration and anxiety develop and a vicious circle ensues. There is a risk of therapists feeling threatened by this ‘failure’ and making self-serving attributions of blame to clients (this client is difficult, unmotivated, lacks the wherewithal to use therapy). Assumptions about competence commonly link with other beliefs, such as those about therapist safety. For example, therapists might think ‘People with psychosis are dangerous so I’ll need to be especially skilful and careful to avoid sparking anything, but I’m not sure I’m up to it’. This mode supports anxiety, fear and a behavioural urge to be over-cautious, passive, to escape (e.g. cancel session) or to actively slow things down. It is important not to judge therapists for having anti-collaborative modes. They seem nigh on universal. The impact of these modes is restricted by awareness of them when they occur, acceptance that they have occurred, and open discussion of them in supervision. One of the most important preparations therapists can do in the moments before meetings with clients is to observe their own experience. What feelings are present? Is there any anxiety? Are there any implicit demands about how things should be going? What worries do we have? Of course, these anticollaborative modes can be triggered throughout therapy, not only in early sessions. In passing, it is interesting to note how the word engagement implicitly reinforces the anti-collaborative assumption that therapists should get the person to stay in therapy. The definition of ‘engaging’ is ‘attractive, charming’ – suggesting that therapists have to attract clients, and may, of course, fail to do so. This is why I prefer the phrase relationship building, which suggests an interpersonal process, to the word engagement. In the next section relationship building is considered in more detail.

RELATIONSHIP BUILDING: ‘MEET THE PERSON, NOT THE PROBLEM’ In PBCT the primary task when meeting clients is not to try to get them to stay in therapy, but rather to establish a relationship that is radically collaborative. A radically collaborative relationship is one that is free from the influence of anti-collaborative assumptions about how therapy should progress. It echoes Rogers’ views: ‘As I try to listen to myself and the experiencing going on in me, and the more I try to extend that same listening attitude to another person, the more respect I feel for the complex

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The Therapist A therapist is 20 minutes into an initial assessment session. The client is clearly very anxious and says little. The therapist feels a growing sense that little or no progress has been made towards forming a collaborative relationship. In fact the opposite seems to be happening; the person seems less ‘present’ than at the outset. The therapist is unsure why this is occurring. The therapist is becoming worried and anxious and is beginning to experience automatic thoughts, along the lines that she is doing something wrong, that she must be missing something, or that she is communicating in a less than ideal way. The therapist begins to have a sense of losing the client, with intrusive thoughts that the client will drop out. The therapist tries to regain a clear sense of focus for the session, returning to the task of assessing the psychotic symptoms. The client still doesn’t seem to be responding. The therapist is finding it harder and harder to be collaborative and open, instead becoming controlling and closed. What should she do? The Client The client is exhausted. The effort of getting to the session was considerable. She hates travelling on the bus, because the paranoia gets worse. For a couple of hours before getting on the bus she was worrying about the journey and her voices warned her not to attend the session, saying foreboding things about the therapist wanting to harm her. Her anticipatory anxiety and fear was building throughout this time. She overcame the urge to avoid – indeed, this urge was strong right up until she sat down in the therapist’s office. For 25 minutes on the bus she experienced people talking, laughing and joking about her, criticising her. She felt too ashamed to meet anyone’s eyes. During the session the client experiences thought echo; she hears her own thoughts spoken out loud after she thinks them. She says less and less, in order to restrict this experience. Her voices are also speaking during the session, abusing her and warning her about the therapist. She cannot concentrate. Already, she is dreading the return journey home. She is unable to think of anything else today. She is just exhausted. But she wants to stay. Once she gets home she will remember almost nothing of this first session, other than a recollection of how arduous it was and how she did at least get through it.

processes of life. So I become less and less inclined to hurry in and fix things, to set goals, to mould people, to manipulate and push them in the way that I would like them to go’ (Rogers, 1961, p. 21).

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Establishing radical collaboration requires that therapists meet the person, not the problem. In the above clinical vignette, the problem is that the therapist has a preconceived agenda for the assessment – a set of tasks that should be covered today. Such therapist agendas often are like a wall between them and the clients, blocking relationship building. In the above vignette, had the set agenda been put aside, what might the therapist have explored? Perhaps something about the person’s journey – for many clients, turning up to the first one or two meetings is an important achievement in and of itself, and something to validate. The therapist might explore whether the person initiated the referral for therapy, or was going along with what others thought best, or how the person felt leading up to the meeting: ‘I can imagine if I were in your shoes I might have some worries about this meeting. Have you had any worries over the past weeks when you were thinking about today’s meeting?’ Most people will have experienced increased paranoia, anxiety and voices leading up to sessions; normalising this is therapeutic in itself.

Client Beliefs As stated by Chadwick et al. (1996), clients also have assumptions that threaten collaboration, yet it is unusual for them to voice any spontaneously. Commonly these concerns relate to fear of being judged, misunderstood and controlled or being given ‘treatments’ that do not help. Therapists driven on by their own anti-collaborative need for change often move straight into assessing presenting problems, which leaves clients’ concerns as unaddressed obstacles to relationship building. Client expectations will be grounded in past experience, and need to be heard in an open, non-defensive way. A therapist might say something like: ‘There is a risk in this type of situation that we will launch into discussing your problems. If that’s what you would like then that is fine. I just want to say that sometimes it is useful not to talk about difficulties straight away. It can be useful first to check out any questions or concerns you might have about today’s meeting, or about me or the therapy’, or perhaps, ‘I know you’ve had a lot of contact with services, and I imagine you’ve come to expect certain things from professionals. What did you expect might happen today?’

RADICAL COLLABORATION IN PRACTICE Radical collaboration is a process of allowing clients to find their own goals within a supportive collaborative relationship that is free from therapist demands about how therapy should progress. Therapists are encouraged

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to let go of anti-collaborative assumptions for the same reasons that they encourage clients to do so. It is unhealthy and unrealistic to demand that other people behave and change in predetermined ways. Making such demands makes therapists’ self-acceptance conditional upon something that is beyond their control. Such assumptions are not client centred. Also, anti-collaborative assumptions are self-defeating for therapists because they threaten relationship building and change, the very things that therapist self-acceptance is pinned to. It might at first appear that radical collaboration leaves therapists to adopt a position of passivity, or apparent indifference. The process is far from passive. Embodying Rogerian acceptance throughout, therapists (1) behaviourally challenge their own anti-collaborative assumptions, and (2) actively listen in order to (3) develop good enough understanding of the person’s experience, which therapists (4) check out using the clients’ language, without colluding, (5) from where they use supported (guided) discovery to facilitate goal setting and change, (6) sharing their own ideas collaboratively and without attachment, (7) with commitment to openness throughout. In the following subsections, these seven themes are described.

Behaviourally Challenge Anti-Collaborative Modes It is important for therapists to behave in ways that support radical collaboration and challenge an anti-collaborative mode. For example, rather than striving to get the person to stay in therapy, therapists communicate that clients are free to decide if they want to attend therapy: ‘There have probably been times when it’s felt like you don’t have much choice about your care. This situation is different. Here you have a lot of control. You can choose if you want to attend. You don’t have to. It’s up to you.’ For newer therapists this can sound like a very good way of losing clients from therapy in their droves. Experience suggests the opposite and reveals a paradoxical relationship – the freer clients feel not to attend, the more likely they are to attend. Again, in order to limit the potential influence of anti-collaborative assumptions of responsibility for therapeutic change, therapists explicitly offer an alternative framework for therapy – one of shared responsibility and collaboration. Therapists look for opportunities early on to establish this collaborative mode. A typical opportunity is when a client asks at the end of an early session, ‘What do you think, can you help me?’, or indeed, when a client asserts, ‘There’s no point, you can’t help me.’ Both statements are highly likely to cue into therapists’ anti-collaborative assumptions about competence and responsibility. It is helpful to reply something like: ‘I’m not sure if therapy will help. I don’t have any special ability or power to take away your distress. What I can offer is a commitment to

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working with you, to see if between us we can come up with some things that you find helpful. How does that sound?’ Many clients with psychosis already fear further loss of control. Clients are reassured by the prospect of a realistic relationship, one in which they choose whether to collaborate, where therapists’ fallibility and limitations are openly acknowledged, and where there is joint responsibility for relationship building and change.

Active versus Associative Listening There are two main types of listening. Associative listening occurs when people listen only for an opportunity to say something themselves. Once a connection with their own experience is triggered, they become selffocused and look for an opportunity to speak, either by grasping a space in the conversation or interrupting. Their non-verbal behaviour communicates a desire to speak rather than listen. Politicians do this a lot. So too do therapists whose anti-collaborative modes are operative. At these times they look for an opportunity to use a technique, or make a point, in order to push for change. The second type of listening is active listening. Here the listener’s only aim is to seek to understand the other person’s perspective. The listener speaks only to pursue this aim, by asking open questions, seeking clarifications to help understand the other person’s position, and using counselling skills such as summaries, paraphrases and reflections. Active listening underpins radical collaboration; it is the correct way to conduct an ABC assessment; it supports understanding of a client’s experience. It is an essential skill that needs practice, and it is hard work.

‘Good Enough’ Understanding How much understanding or empathy is needed in PBCT? Indeed, are understanding and empathy the same thing? In an important review, Burns and Auerbach (1996) clarify how empathy has a specific meaning which separates it from understanding. In its psychoanalytic origins, empathy is a process whereby therapists themselves experience emotions that clients are presently feeling – or even repressing, and are therefore unaware of. This type of empathy is not an aim within PBCT. In fact, research reviewed by Burns and Auerbach shows that therapist feelings (empathy) are not reliable indicators of client feelings. From a CT perspective this is precisely what one would expect. Therapists’ momentary thoughts and feelings are more likely to reflect their own belief systems than those of their clients. Of course, each therapist could be so attached to her intuition as to believe that she is the exception that proves

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the rule! More fundamentally this precise meaning of empathy – as therapist feeling what a client feels – attaches too much importance to what a therapist is feeling. Being provocative, why does it matter if a therapist is feeling what a client is feeling? What really matters is that clients become aware of and articulate feelings and that therapists hear this. Clients do not expect full understanding (see the transcript below). Clients are realistic. Quinn (quoted in Rogers, 1961) argues that what is critical when forming a therapeutic relationship is conveying a wish to understand, not necessarily understanding itself. The following verbatim extract from session 2 with a client illustrates this. The client had been visibly terrified at session 1. Her body jerked throughout, her head hung down and she stared at the floor. She initiated no discussion and said very little in response to open questions. She was startled by any noises from outside, and was regularly distracted by voices. There was no eye contact during the first session. The transcript begins very early in the second session. C: They feed off each other, the voices and the pictures … (trails off, long pause, head jerked to left-hand side). I think that everything I say is stupid. T: Is that what the voices were saying just now? C: It’s what they say most of the time. It’s terrible the things the voices say in the background, the voices are saying in the background ‘you’re stupid’, ‘you’re no good’ (trails off into silence). I don’t think I’ve explained myself clearly. T: What’s it feel like to be sitting in a room with someone you think is not understanding you? C: It’s distressing because I think that they think I’m very stupid or not clear. And I’m not making myself clear and being a bit useless really. T: So the voices are really powerful, aren’t they, because they can say to you that you are not being clear, that you are being stupid, and you believe them and you also think that’s how I see things and that’s really distressing for you? Silence. T: I suppose one thing that occurs to me is that lots of people I talk to who hear voices say that really it’s extremely difficult for someone who doesn’t hear voices to understand what it’s like. And it would be understandable if you had that concern here, maybe something like ‘he can’t really understand what it’s like’. C: Sometimes I think, um … I don’t know … It’s like the voices are telling me that you can’t understand (long pause). It’s just because you don’t know me. T: It must be really difficult for you to be in a situation like this, trying to work in therapy, trying to put some trust in me, yet the voices keep on at you telling you that I don’t understand, or undermining things.

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I suppose what I was wondering is what would it mean for you if I really didn’t understand. If other people couldn’t understand you. What would that mean for you? C: I’d feel isolation. Confusion. I’d feel like everything I say is always going to be taken the wrong way or is not true. Silence. T: So it’s really important for you that some people do understand something of what you’re saying. C: Yes. I’ve got some people I can trust, to a certain extent. That’s very important to me. Silence. T: I’m wondering if you can imagine somebody not understanding some of the things that you say, but still being concerned for you and wanting to work with you to try to understand. Would that lead you to feel isolated and distressed? C: If someone like yourself, if you could understand me, or try to understand me, that’s important. At least you’re not saying ‘oh she’s bad’, you’re at least trying to help me and, uh, from what I’ve seen of you it looks like you do understand a bit and you’re trying to understand and that’s important to me. T: That’s important. That in a way I won’t understand everything, but if we can work together I will hopefully understand enough to make the therapy work. I suppose what we are drawing out is that in a way people not understanding some of the things that you are saying is maybe okay if they are concerned for you, if they don’t think bad things about you. C: It’s like my mother. Most of the time she can’t understand the voices and that, but she, she tells when I’m under stress sometimes, which is very important. Even though she doesn’t understand it, she does notice the results.

Negotiating a Common Language Developing a radically collaborative relationship involves finding a shared language. This is an ongoing process. To begin with therapists try to understand clients’ experience, in the clients’ own language, metaphors and imagery. The therapist uses this language when clarifying, summarising or reflecting during active listening, ABC assessment, etc. Once therapists have gained an initial understanding of the person’s perspective, they then begin to introduce their own perspective in words and images that are likely to be acceptable to the person. Therapists and clients then negotiate a mutually acceptable dialogue and framework that reflects and expresses both perspectives.

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Finding a shared language is about timing, not about outlawing disagreement or therapists feeling gagged. So, for example, if a client says that the neighbours were spying on him last night, a therapist’s first aim is to understand – this requires movement to the client’s perspective, without colluding. A therapist might reflect back ‘so your experience at that time was … ’ rather than ‘so you believed that … ’ The word belief often implies scepticism if it is used at an early stage. Later, when the relationship is stronger and the cognitive model better understood, the word belief can be useful. When therapists introduce words it is important to recognise that the same word can have different meanings for different people. In our mindfulness groups I and colleagues talk a lot about acceptance of voices, paranoid thoughts and images. In one group a person hearing very derogatory voices understood accept to mean agree with – acceptance and agreement are often used synonymously in everyday life. For someone else acceptance might suggest a helpless, passive resignation. When using a word or phrase to articulate a key concept it is important to check what people understand by it, to be clear what was meant by it, and to agree if the word is then part of the common language or whether an alternative is needed. One aspect of negotiating a language is avoiding jargon and labels. As Rogers (1961, p. 34) says of person-centred therapy: ‘there is also a complete freedom from any type of moral or diagnostic evaluation, since all such evaluations are, I believe, always threatening’. For me personally this issue poses a dilemma when writing about therapy. In therapy itself, things feel straightforward. I have never used the words delusion or schizophrenia (or any of its derivatives). I do not use the word psychosis with clients; voices and paranoia are words used commonly by clients themselves, and I use them in therapy. But in writing, things are more difficult. I experience at times a need to describe a class of beliefs, and a group of people who share certain experiences (each with a unique personal flavour). I have used the word delusion in writing over the years because it communicates efficiently, but with a growing unease. In this book I use the phrase symptomatic meaning instead – where this is intended to mean symptomatic of distress, not of an underlying illness. I suspect that this is still not ideal. I continue to use the word psychosis in writing because it grounds the work in a relevant literature and clinical context. Yet I would like clients to feel comfortable if they read my work. When feeding back findings from a qualitative group-based research project to participants, one man found this term particularly objectionable – I apologised and explained why it was used.

Supported (Guided) Discovery It is central to the concept of the ZoPD that therapists do not merely need to understand a person’s perspective, but to begin the process of

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collaborative exploration from that standpoint. Padesky (1993) has a very useful summary of the process and goals of Socratic questioning and guided discovery. She clarifies that the purpose of Socratic questioning is to guide discovery and not to ‘change minds’. As I have discussed above, therapists often are driven to try to ‘change minds’ by their implicit assumptions about how therapy should progress. They try to change clients’ minds in order to ease the discomfort and anxiety they feel. When therapists are being radically collaborative, they are naturally drawn to Socratic dialogue, with its openness and curiosity. Of particular importance within PBCT are two qualities of Socratic dialogue – those of drawing attention to material that is currently outside awareness, and supporting metacognitive insight from new experience. Padesky notes how guided discovery works best when therapists do not have a clear, fixed endpoint in mind. All too often in practice therapists misuse Socratic dialogue to lead clients to say what therapists are already thinking. Clients sense that there is a ‘right answer’, find themselves thinking ‘What is it you want me to say?’, and can feel patronised, manipulated and belittled. This is the antithesis of collaborative proximal development. In my practice I use the phrase supported discovery rather than guided discovery. I find it communicates more clearly a radically collaborative stance, because in ordinary life guides usually know where they are going and are leading someone to that place. Supported discovery more clearly expresses a collaborative social process of discovery.

Sharing Ideas Openly, without Attachment When placing methods like active listening and supported discovery at the centre of therapy, a risk arises that therapists might feel a little gagged, a little passive, even disempowered. Therapists can begin to feel that they must never offer a view or opinion, but only endlessly draw out what is in the person’s mind. This is very frustrating for clients. I remember an important learning experience on a workshop. The therapist was completing an ABC assessment of a role-play where the ‘client’ felt depressed. The situation and emotion had been drawn out, the automatic thoughts were clear and the therapist was thought chaining for a negative schema. The chain was stuck. The therapist was frustrated because he sensed that the NSS seemed to be about failure – all the NATs were on this theme. The therapist tried every which way of wording questions, and then called over the workshop leader, Paul Gilbert. The frustration was described. Paul asked, ‘Why don’t you share the idea you have in mind?’ A relieved therapist asked, ‘Is it okay for me to do that?’ ‘Of course – it’s collaborative,’ was the reply. Collaboration is a two-way process. Therapists need to contribute. The crucial thing whenever sharing ideas is to do so tentatively and

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speculatively. This is in keeping with the Kantian philosophical underpinnings of PBCT, which assert that we all operate in a world of appearances (see Chapter 1). So a therapist might say: ‘I don’t know if this is right. You know when the voices tell you you’ve screwed up and that you are a failure. I am wondering if sometimes you believe this yourself – if you experience yourself as a failure at those times.’ When making sense of a client’s experience according to an aspect of a cognitive theory, it helps to share this in plain words, without jargon. So, if in the present example the client replies that he or she does feel like a failure when the voices say these things, the therapist might add something like: ‘Right. The reason I was thinking that you might see yourself in that way was that you said you felt depressed when the voices called you stupid and crap. Usually when we feel depressed we are seeing ourselves as lacking in some fundamental way. If you thought the voices were wrong to label you crap, I could imagine you might feel something else, maybe anger, but not depression.’ If a therapist shares a view with clients, and it is ignored or has little impact, then therapists can feel undervalued or unappreciated, or even doubt themselves. This reflects another form of the anti-collaborative mode, where therapists’ implicit assumptions lead them to demand clients behave in certain ways (i.e. change, appreciate my contributions). The art is to share ideas and models with clients openly and tentatively in order to learn about their potential for movement within one or other domain of the ZoPD (see Chapter 3) – not to get them to change.

Commitment to Openness One essential requirement of radical collaboration is openness about the nature of the therapeutic relationship and its context. This includes clarifying how much influence clients and therapists have over, for example, length and number of sessions. It means being open about confidentiality – if, for example, any team member has access to case notes, then tell the client this. It means being explicit and open about how a decision would be reached to end therapy. Openness is also about self-disclosure. It means being willing to disclose aspects of who you are and how you feel when with your clients – though if feelings are current or in the recent past, it is prudent to have in mind a crucial CT distinction between mild and severe emotion, and to disclose only the former. Openness extends beyond the therapy room. It means copying all letters about a client to that client. I have done this for the past seven years and have yet to find an occasion when it could not be done. It makes therapists write to other professionals without jargon in a client-centred language; it is a skill acquired through practice and commitment. Fundamentally it is about a shift in one’s position away from in-group (i.e. professionals)

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writing about an outsider (client) to the person being at the centre of all communication.

POSITIVE ASSUMPTIONS THAT SUPPORT RADICAL COLLABORATION I have discussed above how therapists’ anti-collaborative assumptions threaten radical collaboration. Following Linehan (1993), and in line with an emphasis on construction of positive and valued meaning, in this section I articulate those positive assumptions about people with psychosis and the process of therapy that underpin practice of PBCT and radical collaboration. The assumptions presented here are not intended to be original, and there is no attempt to back them up empirically. It is useful to reconnect with and embody these assumptions regularly. This is particularly so at times of therapist stress and anxiety, when it is important to decentre from anti-collaborative assumptions and ask oneself, ‘In this moment, what am I demanding? What is lacking?’ This reveals which anti-collaborative assumption is operative, and points to which positive assumption to connect with. Connecting with positive assumptions means emotionally and not merely cognitively. For example, I am prone to feeling responsible for clients. At such times one of the things that is lacking is a confidence in clients’ own self-efficacy – it helps me when I remember to look over to my desk at two gifts given by clients whom I like and admire very much and who represent for me clients’ capacity for self-efficacy.

Assumption 1: The Core of People with Psychosis is Essentially Positive There is an art to working with people with distressing psychosis. Therapists need to be open to the depth and complexity of clients’ emotional experience and belief systems, without losing an authentic sense of confidence in clients’ capacity to find greater emotional well-being, self-acceptance and meaning in their lives. A fundamental assumption in PBCT derives from Rogers’ (1961) view that the ‘core of man’s nature is essentially positive’ (p. 73), or stated more fully: ‘It has been my experience that persons have a basically positive direction … The words which I have found most truly descriptive are words such as positive, constructive, moving towards self-actualisation’ (p. 26). This positive tendency for self-actualisation remains accessible however distressed or disturbed people are. ‘In a suitable psychological climate this tendency is released, and becomes actual rather than potential … the individual becomes more integrated, more effective. He shows fewer of

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the characteristics which are usually termed neurotic or psychotic, and more of the characteristics of the healthy, well-functioning person’ (1961, pp. 35–36). Assumption 1 is not a spiritual view on a person’s essence. Within PBCT it is a practical statement about how given certain therapeutic conditions (described in this book) clients with distressing psychosis can move towards emotional well-being and self-acceptance. This assumption is an optimistic and hopeful stance – no one is ever a lost cause. This is, perhaps, doubly important for people with psychosis, many of whom not only feel overwhelmed by their psychosis, but also feel judged by others as fundamentally mad, or bad, or both. PBCT is intended to facilitate clients to connect with and express their positive core.

Assumption 2: Psychotic Experience is Continuous with Ordinary Experience Jaspers (1962) used the metaphor of an abyss to characterise what he saw as a discontinuity between psychosis and non-psychosis. A different assumption underpins PBCT theory and practice – that is, that there is no clear divide. In a landmark paper, Strauss (1969) argued that delusions and hallucinations were not ‘present or absent’ phenomena. Instead, Strauss argued that these were multi-dimensional phenomena that lay on continua functions with normality. Position on these continua was determined by different dimensions, such as degree of distress, belief conviction or preoccupation. It is our view that any person, given the ‘wrong’ set of circumstances (e.g. prolonged trauma or sleep deprivation), might experience unpleasant voices, paranoia, images, etc. This does not imply that they might develop a mental illness; PBCT is not based in an illness model. Rather it implies that these experiences are part of the ordinary range of human responses to environmental stress – accounting for why these experiences are common in the general population.

Assumption 3: Therapists’ Responsibility is to Radical Collaboration and Acceptance Within PBCT a therapist’s responsibility is to radically collaborative exploration of a person’s ZoPD. Therapists’ central responsibility is to remain committed to this therapeutic process, rather than to achieving a clinical outcome. It is critical for therapists not to assume responsibility for their client’s progress – one of the hallmarks of an anti-collaborative mode. Therapists and clients share responsibility for therapy, and outcome will depend on an interaction among client, therapist and therapy (Chadwick & Lowe, 1994). Therapists are no more fully responsible for

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clients who feel better than for those who feel worse. Like Linehan (1993, p. 108) we believe that neither client nor therapist can fail in therapy, so long as therapists have applied therapy with reasonable competence. Failure would imply that there was something that should have been achieved. Therapists embracing this assumption can be open to and accepting of all outcomes of therapy and are more likely to learn from the process than if they are driven by anti-collaborative modes. At times, there is a risk that health care provision for people with psychosis seems to communicate an implicit or explicit conditional acceptance of clients. It is implied, or clients infer that they would be acceptable if their ‘symptoms’ could be removed. Getting rid of symptoms is not an aim in PBCT. Rogers (1961) asserts the need for unconditional acceptance and respect for clients and the entirety of their experience, and this includes psychotic experience. This therapist stance facilitates clients to accept their own experiences of psychosis as a part of the self, but not the self – a point implicit in Assumption 1 also.

Assumption 4: Effective Therapy Depends on Understanding Sources of Distress, Not Sources of Psychosis PBCT is grounded in understanding sources of current distress, not psychosis. In fact the approach is silent about the aetiology of psychosis – it is not an illness model. I do not believe that effective therapy requires a theory for the emergence of psychosis (and am dubious that such a theory is possible). The sources of the sensations that enter people’s awareness do not need to be known in order to understand how their reactions to these sensations create distress, or how this distress can be alleviated. To make this point differently, the Buddha is reputed to have said: If you are shot with an arrow, will you consent to have it removed only when you know who fired it, why, where it was made, by whom and using what wood? There is a common fallacy that the aetiology and ‘treatment’ of a condition have to operate through the same mechanism. In other words, people reason if a problem is biological in origin, then only a biological treatment can alleviate it. This is fallacious: psychological interventions (e.g. relaxation therapy, meditation) can alleviate physical problems (e.g. headache), and vice versa. There is no necessary connection between aetiology and treatment.

Assumption 5: Therapists Aim to be Themselves More Fully with Clients Therapists cannot avoid setting norms within a therapeutic relationship. Even a therapist who says little and tries to be a ‘blank slate’ is setting

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powerful norms for the relationship. In our view it is as well to accept and work with this by modelling interpersonal behaviour that is person based – both in terms of meeting the client as a person rather than a set of problems (see above) and being a person oneself. Rogers (1961) explicitly encourages therapists as well as clients to be themselves more fully in their work with clients. This links with Kabat-Zinn’s (1990) assertion that in life we cannot be anyone else, only ourselves more fully. It is an important developmental aim for therapists to learn to be themselves more fully with their clients. Often in supervision supervisees seem to have an implicit assumption that runs something like ‘in order to be an effective therapist I need to understand and conceal or get rid of who I am as a person’ – an ironic mirroring of the conditional acceptance clients routinely experience. In fact when watching effective therapists work it is clear that the opposite is true – that is, ‘the more fully I can be myself with clients, the more I am likely to help them change’.

CONCLUSION In this chapter I have argued that when working with people with distressing psychosis, where therapeutic change can feel arduous, it is necessary to go further than traditional CT in our efforts at relationship building – to be radically collaborative. This requires a commitment to meeting the person, awareness of anti-collaborative assumptions about what should be achieved, and radically collaborative acceptance of the way things progress. Radical collaboration is characterised by a range of attributes, such as active listening, supported discovery, and clear open discussion of issues such as responsibility, choice and confidentiality. Radical collaboration is liberating, enjoyable and exciting, and creates a context within which to use those specific methods and techniques that facilitate exploration and change in a person-centred way.

Chapter 3

FRAMEWORK FOR PBCT: THE ZONE OF PROXIMAL DEVELOPMENT

OVERVIEW The prime basis for formulation within PBCT is the Zone of Proximal Development (ZoPD). The ZoPD is intended to be comprehensive, and comprises four sources of distress with linked behavioural disturbance – symptomatic meaning, relationship with experience, schemata and symbolic self. These are all cognitive domains, rather than hierarchical levels. The ZoPD framework is used to conceptualise in each domain not only the sources of clients’ distress and disturbance, but their strengths, positive attributes, insights and other sources of potential development. One important aspect of proximal development in all domains is the person’s capacity to learn metacognitive insights about sources of distress and well-being. Exploration of all four domains is infused with Rogerian acceptance and radical collaboration.

ZONE OF PROXIMAL DEVELOPMENT (ZoPD): A FRAMEWORK FOR THE PROCESS OF CHANGE A ZoPD is a conceptualisation of collaborative learning – it defines that change which is possible through collaboration. It is the central framework for the process of PBCT, and the essence of a person model (Chadwick et al., 1996). Where a traditional medical framework is static, impersonal and emphasises products (outcomes), the ZoPD depicts a dynamic, dialectical, interpersonal therapeutic process. PBCT was defined in Chapter 1 as a social process, whereby with the support of a radically collaborative and skilled therapist a client eases distress, develops metacognitive insight and achieves self-acceptance through proximal development in all four domains. In all four domains working with strengths and positive attributes has equal importance as sources of distress and disturbance. For example, with schemata, formulation of a PSS is at least as important to the process of therapy as formulating a NSS.

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Symptomatic meaning concerns working directly with symptoms – paranoia, beliefs about voices, visions, etc. – the focus of our earlier book (Chadwick et al., 1996). Relationship concerns learning to respond mindfully to unpleasant psychotic sensations, and letting go of habitual distressing reactions (experiential avoidance, rumination, etc.). Schemata concerns working with negative schemata of self and others, to reduce associated distress, and developing PSS. Symbolic self is a metacognitive representation of self accommodating negative and positive schematic experience, and expressing acceptance that the self is a complex, contradictory and changing process.

Exploration Begins from a Client’s Perspective Exploration of proximal development must begin from where clients are, rather than where therapists might wish them to be. It is a client’s ZoPD. The first task is therefore, without colluding, to establish a ‘good enough’ understanding of the person’s experience, from where to begin radically collaborative exploration of proximal development in the four domains. Determining the ZoPD is the collaborative work of therapy – it is impossible for a therapist to know in advance a client’s ZoPD. The goal for therapists is thus to facilitate areas of proximal development, rather than following their own assumptions about how therapy should progress (see Chapter 2). Exploration and change are neither linear nor static processes – a client’s developmental potential for therapeutic change is broad and changing. Having said this, joint exploration needs to be proximal. This means not over-reaching, but working with what is possible given where a person is now. To make this point concrete, imagine a client who is totally convinced that he is a victim of persecution. It would not be sensible for the therapist to come straight back with an invitation to the client to consider that this is a belief which may or may not be true. Therapists often do this because they feel that in suspending their own disbelief they are meeting a person halfway. Well, halfway is unlikely to be good enough because it requires a client to move from a starting position of ‘this persecution is a fact of my experience’, to viewing it as a belief which may or may not be true. What is needed at this early stage is effort to further explore the person’s experience, rather than introducing a new perspective and trying to ‘get people to change’. For example, therapists might explore whether clients have any current doubt at all, or have ever doubted their beliefs – or what would have to happen in order for them to do so (see Chapter 4 for details of exploring doubt). Finding that a person has doubted a belief, or that he has not, both reveal important aspects of a person’s ZoPD.

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Using the ZoPD to Conceptualise and Guide Therapy Within PBCT it is always distress and linked disturbance that is formulated, not symptoms or syndromes. As befits any framework for case formulation, the ZoPD is intended to promote conceptual and practical clarity, and to facilitate therapists in responding flexibly and creatively to clients’ needs. It is collaborative, person-led discussion that determines the specific therapeutic goals for each domain, which in turn determine the specific methods. Therapists can draw freely from CT and other schools of therapy to find techniques that serve the specific aim and are acceptable to the person. One of the challenges of working with people with distressing psychosis is being open to the range of problems and therapeutic opportunities, without feeling lost or overwhelmed. This requires clarity about which of the various aims is being explored in any moment, and close collaboration and negotiation between therapist and client. Confusion can arise because a specific experience can be associated with distress in different ways. For example, imagine a client who is distressed by a derogatory voice saying, ‘You are worthless, you should kill yourself.’ The distress might reflect aspects of symptomatic meaning – perhaps a belief that the voice is a dead parent who is punishing the client for particular actions. It might be distressing because the person reacts with struggle and rumination – an issue of relationship. It might be distressing because the voice actuates a negative self schema about inadequacy – schemata. It might be distressing because the person’s metacognitive sense of self comes to be defined by the judgmental voice – symbolic self. And it might be a combination of two or more of these. The ZoPD helps prevent therapists focusing on only one source of distress. For example, in practice cognitive therapists commonly concentrate on exploring the source of a voice, working collaboratively to consider the possibility that a voice might originate in a client’s mind, rather than externally from another person or being (establishing a symptomatic alternative: see Chapter 4). Therapists can become confused and despondent if they find that this cognitive reattribution is successful, but does not alleviate distress associated with the voice. This is because even when attributed internally, the voice still might, for example, actuate negative schemata, or be met with experiential avoidance and struggle.

PBCT AND CASE FORMULATION MATERIALS The ZoPD is the central formulation within PBCT. It does not require therapists to place the four sources of distress in one linear sequence. Each sits side by side as both a source of current distress and an area of possible proximal development. Strengths and positive attributes exist in

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all four domains and are identified and used within therapy. In Chapter 1, Figure 1.1 presents the ZoPD diagrammatically and is primarily intended for therapists, to help them conceptualise and structure PBCT. A more useful shared formulation of the ZoPD is a formulation letter. This practice comes from Cognitive Analytic Therapy (CAT; A. Ryle, 1995), although, of course, the cognitive conceptualisations differ. Letters offer a unique way of describing sources of distress, positive attributes and proximal development in each of the four domains, while also being able to address the therapeutic relationship. In addition, we find it useful to develop shared formulations of symptomatic meaning and schemata. Traditional developmental diagrams are little used in PBCT, and perhaps have most value in groups where therapists wish to develop a general group formulation (see below). We find it unnecessary to formulate the symbolic self separately.

FORMULATION LETTERS Our use of formulation letters comes from CAT and we use a similar structure. Unlike in CAT, there is no attempt to share letters at a fixed session. It can take 10 or more meetings before therapists are ready to share a formulation letter in PBCT. Any important differences in perspective between therapist and client are openly acknowledged in letters. Letters contain the following types of information: (1) Authentic positive statements about therapists’ experience of client strengths, attitudes and attributes, and how they are in the therapeutic relationship. For many clients this is a straightforward task. For a few it will be more difficult, yet it is still always possible to identify some positives – perhaps a person’s commitment in trying to attend all sessions, even when feeling hopeless about life, or perhaps something about their potentialities (see acceptance, Chapter 1). (2) A formulation based in the ZoPD framework is articulated. This is not a slavish conformity to a set sequence. Rather therapists are encouraged to use the framework flexibly to reflect on, clarify and organise a person’s sources of distress, strengths and potential for change. In our experience, the most common danger with formulation letters is that in immersing themselves in narrative, therapists lose the clarity of the model – for example, in practice when discussing schemata, rules are often omitted. Jargon is not needed (e.g. labelling beliefs metacognitive), but it is important to remember that this is a CT. (3) Positive alternative rules and schemata are included. Usually Socratic dialogue would have helped a client articulate these positive alternatives prior to a formulation letter, but if this has not been done, then

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therapists might offer an alternative – doing so tentatively, in keeping with radical collaboration (Chapter 2). (4) Clear views are expressed about possible collaborative proximal development (aims), ideally in all four domains. Following CAT, likely threats to the person achieving his or her aims are also drawn out, based on the formulation. For example, a person who fears disappointing and failing might be striving to please the therapist and suppressing his own anger or disappointment with the therapeutic process. (5) Explicit reference is made to personal strengths, qualities and achievements in life. These might be from any area, such as familial, occupational, spiritual or social (e.g. maintaining a relationship with a friend). Two illustrative formulation letters are reproduced, with the clients’ permission.

Dear Alan, We have been meeting now for about four months. We began meeting because you were very preoccupied and distressed by your experience of the world. You have been an inpatient for 18 months, and have lived in fear and confusion for a long time. You believe there to be a ‘huge conspiracy’, spanning many years, which involves powerful people controlling your mind (thoughts and feelings) and thereby your actions. You have labelled this experience Hypnoaversion to communicate both how you feel controlled hypnotically and how the essence of who you are as a person feels twisted, warped and turned inside out (aversion). The control is achieved through voices, and other ‘strange’ experiences such as the television and radio communicating with you. The only way you can make sense of it all is to believe that you are part of a huge experiment. Recently you have wondered if there is a ‘grand purpose’ behind it all. These experiences feel so real that it seems to you that anyone who had lived through them would believe what you believe. We have very gently set out two possibilities – either you are subject to a lifelong conspiracy to control and harm you, or the voices and paranoia originate from your own mind, and perhaps link to your earlier traumatic experiences and what you call your temperament. Currently it’s hard for you to consider this second possibility. In the past you have doubted your beliefs, and I am struck that you felt much less distressed and more connected with others at these times. Home life you remember as ‘always difficult, always upsetting’. You felt ‘torn apart’ by the manner in which your parents separated. You

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recall thinking that you always got things wrong, and feeling guilty. Secondary school was also very difficult, and you recall feeling isolated and different. You had some traumatic sexual experiences as an adult. You were rarely assertive, and remember being ‘savagely put down’ once when trying to defend your sister, whom you love and trust. You learned ‘If I get angry, I get punished’, and an interpersonal rule, ‘I’m acceptable only if I comply with others’ wishes and needs’. As you put it, ‘I’ve never been my real self’. I think you have shown resilience to get through these experiences, and deep loyalty and love to your sister throughout. Finding the ‘real Alan’ You describe how it seemed as if the only self you have known feels ‘shameful, bad, perverted, idiotic, always getting things wrong’. Now, you are connecting more with what you call the ‘real Alan’, who is sensitive, compassionate and decent. Using two chairs is helping, though I appreciate is difficult – I remember the occasion when you barely had time to sit in the positive self chair before the voices and judgements began. I and others often see and like the real Alan, like when you recently comforted your sister. Mindfulness is helping, though it is difficult for you to observe voices, thoughts and images, rather than getting lost in struggle, judgement or rumination. Mindfulness gives us a way of easing your distress without discussing content of voices and beliefs, which keeps us more connected when you are very agitated. Leaving hospital remains something you would like to happen when you feel safer, but is not a priority at present. I appreciate your commitment, courage, humour, courtesy and decency and feel we have developed a strong, collaborative therapeutic relationship. I understand that it is hard for you to trust me – indeed anyone. There are times when you view me as yet another person who wants to control and persecute you. My role certainly is not to try to change the way you think, or in any way control you. My commitment is to collaborate with you, and see if together we can ease your distress and improve your quality of life. I hope the letter contributes to this process.

Dear Steven, We have met 15 times since last July, and I thought it might be helpful to try to summarise what I think is our common understanding of the problems you experience, and a possible way forward. I have valued your commitment of valuable energy to therapy. I also value your

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humour in the face of it all, your honesty, and way of depicting the different aspects of your ‘self’ in ways that help us to move forward. You have described your childhood as ‘living in utter terror’, being ‘absolutely terrified of speaking’, and understandably as ‘hiding all the time’ and being vigilant for danger. The level of shouting, violence and bullying was extreme and enduring. You have managed for many years to keep going in spite of the legacy of these experiences, but found two or so years ago that you ‘no longer had the reserves to beat it’ and became very suicidal. The heart attack has clearly closed off a whole way of coping through exercise. The current experiences seem to be a mixture of visualisations of suicide, and a powerful critical ‘voice’ (but not hallucination) that we have called Hammerhead. These are associated with powerful feelings of depression and hopelessness. As we saw when using the two chairs, Hammerhead is ‘extremely damaging, depressing, takes away loads of physical energy, makes me physically sick, and makes it very hard to care for myself’. Hammerhead is a current legacy of the bullying and abuse you have experienced. What adds to your distress is ‘depression about depression’ – that is, telling yourself ‘I should be able to cope without help’. This rule then leads you to judge yourself as ‘crap, weak, useless’ for using the available support. It feels important to find the language to express a more compassionate and accepting alternative view of your life, including your choice to use available help, to counterbalance Hammerhead. It also feels important to acknowledge the strength it has taken to ‘survive 40 years of relentless bullying’. I have been struck by your view that Hammerhead is not your true self, but a squatter, a learned habit. Your true self, which we have called Little Voice, you have called ‘compassionate, measured, humorous, always speaking good sense’. Remembering to connect with Little Voice is difficult, but perhaps we could explore ways you might try to do this more often. As you put it, ‘if I could just train myself to know Hammerhead is not me, I’d be away’. Being alone with nature is clearly a powerful experience for you. These times you have described as ‘soothing, relaxing, peaceful and totally stress free’. There is a connection with your surroundings, and a sense of your ‘place in the scheme of things, not importance, but a place of equality with all living things’. You have also said how you appreciate nature from an artistic standpoint, the ‘best painting in the world’. This shows how your problems are not your whole self. Understandably you want ‘lasting peace and freedom’, a state where ‘anything negative didn’t affect me’. This hope is far from how things are and therefore can lead to disappointment and hopelessness; it is probably what the majority of people hope for but do not have. I think

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your recent idea of ‘tipping the balance’ by increasing space for Little Voice and decreasing time spent engaging with Hammerhead feels realistic and within your control. Mindfulness might help with this. It offers an alternative to struggling against Hammerhead, or being spun into depressive or angry rumination. Relating mindfully to Hammerhead builds on those times when you have noticed Hammerhead start, not reacted to it, and it has ‘deflated’. I guess if there is a risk for the future it might be that you will feel that nothing can really change, and not really realise your own potential to change your life.

Client Letters As in CAT, I invite clients to write a summary of their understanding of therapy so far, and their ideas for how they would like things to develop. I make this an open invitation and if people decline, encourage them to tell me their views instead. Writing a letter can become a source of anxiety for clients – something to have to ‘get right’, for example. In practice, fewer than half the people invited choose to write a letter. An example of a client letter follows. The letter is an impressive and skilful shaping of the therapy agenda. The client states explicitly those aspects of her experience that she would like to prioritise in the next stage of therapy. This is significant because for this client her voices and paranoia were often so strong during bus journeys to sessions that she struggled to place things on an agenda, especially at early sessions.

Dear Paul, It’s Monday 11 p.m. and I have been trying to write this letter since we met last Wednesday. I’m not sure what is to be included in it, but my understanding is that we should write about our feelings on how our therapy sessions are going: good and bad points, and how I want us to progress. I was very nervous when the sessions started, but you quickly made me feel relaxed by your manner and approachability. I have come to trust you because you seem to know what I’m talking about. When I talk about my voices you don’t just say I should block them out and forget about them, but try to deal with them in a constructive way. You acknowledge that the voices are very real for me. I find very useful the frequent recaps on how we are going in the session, because I feel that sometimes I need to reflect on what we have talked about and to put it into some sort of order in my mind.

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I found the exercise in controlling my voices useful. It is good to know that sometimes I can control the intensity of my voices; but this strategy is impractical anywhere other than in private, and not if, for example, sitting on a bus. I need more coping mechanisms, especially at night which will deal with visual as well as auditory hallucinations. Mindfulness sometimes helps, sometimes I can’t even use it. In future sessions I would like to explore the way in which I see myself and perhaps change my, up till now, fixed ideas and visions that I have about myself. The exercise with the two chairs was very useful for dealing with the above. Also, in future I think I still need to talk more about the sexual abuse, my relationship with my mother, and the strange relationship with the rest of my family. Finally, as we talked about last week, we could, with the help of my GP, look at reducing and eventually phasing out my medication. This is the conclusion of my letter to you. It has been useful writing this and I hope you find this letter equally useful.

FORMULATING SYMPTOMATIC EXPERIENCE: THE ABC FRAMEWORK The main method for formulating symptomatic meaning and experience remains the ABC framework. This was the guiding framework in our earlier book (Chadwick et al., 1996). It is clear and easily shared with clients and others. The ABC framework is at its most useful when formulating the link between symptomatic meaning and distress/disturbance. It is important to keep in mind that it is distress that is being formulated, not psychosis. The fact that a person experiences psychosis does not automatically mean that psychosis is what needs to be formulated – it is whatever drives the distress. James had experienced three brief episodes of psychosis, each marked by beliefs which suggested intriguing links to his life experience. Seeking to formulate these beliefs was tempting. Yet they did not distress him, other than when acutely unwell. His current distress lay in the shadows. He still had not taken a step towards finding work. He was anxious and painstaking in therapy, not simply because of the content but also the process. It felt like he was worried about failing somehow. Once we looked away from the psychosis, pieces started to fit together. He was a man with a lifelong fear of being a disappointment and failing to meet people’s expectations. He worked very hard to control anxiety and prevent low mood: he hid any signs of ‘not coping’, routinely over-prepared for tasks and would blame and confront others angrily if things began to go wrong. He was so shocked by his psychosis, especially the threat it posed to his need to cope and be in control, that the anxiety

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was either ignored or viewed almost as an epiphenomenon – yet it was this that needed to be formulated. The psychosis appeared to be what happened at crisis points when the effort and strain of trying to maintain habitual coping behaviours became too much.

ABC Formulation of Distressing Voices and Visions All ‘hallucinations’ are sensations (As) in one or other modality (auditory, visual, etc). They are problematical only if they are associated with distress (Chadwick et al., 1996). All sensations (As) are transient and uncontrollable. Thus while it is clinically helpful to label some sensations as intrusions/intrusive, it is probably conceptually confused – the ‘intrusive’ nature of thoughts or voices says more about their impact (i.e. the Bs and Cs) than anything distinctive about the sensation itself. Furthermore, sensations (1) belong to the subject, (2) are tied to a particular site in the body, (3) are modality specific and (4) occur in the present (Humphrey, 1993). The criterion of sensations ‘belonging to the subject’ might seem at odds with a person’s experience of a voice as quintessentially ‘not me’. There is no inconsistency. A sensation is said to belong to a subject in the sense ‘this is happening to me’ and not the sense ‘I created or am the source of this sensation’ (which would be at odds with a ‘not me’ perception of voices). If I hear a telephone ring I do not think I generated the sound, even though I am comfortable asserting that the sensation of hearing ‘belongs to me’. A further feature of sensations, which comes from mindfulness traditions, is that they carry a feeling tone. This is not the same as an emotion, which is laden with meaning and psychological reaction. A feeling tone is described simply as being pleasant (e.g. classical music), unpleasant (e.g. physical pain), or neither pleasant nor unpleasant (sometimes called neutral). When practising mindfulness, noting the feeling tone as well as the sensation has been helpful to some clients (e.g. ‘unpleasant voice’; see Chapter 5). It is never the goal to try to change a feeling tone, only distress that arises from reaction/meaning. With voices this poses a considerable measurement problem. If the argument that sensations carry a feeling tone is correct, then this will not change following intervention even if distress occasioned by reactions to the voice does. Measures of affect linked to voices therefore need to distinguish intrinsic unpleasantness from psychologically generated distress. In our original cognitive ABC model of voices (Chadwick & Birchwood, 1994) we proposed that people’s emotional and behavioural reactions to voices would reflect not only content and form, but also meaning. Our research indicated the importance of beliefs about identity, purpose (is the voice malevolent or benevolent?), omnipotence and the consequences of compliance or resistance. We showed how beliefs about voices were

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indeed correlated with distress, with robust associations between malevolence and resistance (struggling against the voice and negative affect), benevolence and engagement (engaging willingly with the voice and positive affect), and omnipotence and depression (Birchwood & Chadwick, 1997; Chadwick & Birchwood, 1994, 1995, 1996; Chadwick, Lees & Birchwood, 2000a). Following the important work of Morrison and colleagues (Morrison & Wells, 2003; Morrison et al., 2000), in Table 3.1 we distinguish metacognitive beliefs about voices in a revised ABC model. The central importance of people’s perception of auditory hallucinations as very powerful was first described by Bauer (1970). In a seminal paper he observed how voices can be imbued with a ‘terrifying and compelling quality’ and how individuals can feel ‘caught in a voice’s power’ (p. 169). Perceived omnipotence of voices was central to our cognitive approach to voices (Birchwood & Chadwick, 1997; Chadwick & Birchwood, 1994). Chadwick and Birchwood (1995) presented the Beliefs About Voices Questionnaire, a 30-item measure of people’s beliefs in a voice’s malevolence or benevolence, and a range of emotional and behavioural reactions. Chadwick

Table 3.1 ABC formulation of distressing voices Situation (A)

Meaning (B)

Distress (C)

Situation (e.g. low mood and isolation) and unpleasant voice (content, volume, location)

Symptomatic beliefs Not me: external origin of sensation Identity: who is it? Meaning: why me? Malevolence (bad me or poor me) or benevolence Omnipotence: power, omniscience, control and compliance (e.g. ‘If I do not resist, the voices will take over completely’) Schemata Other-self (voices see me as perverted) Self-self (I am totally rotten) Self-other (voices are totally powerful) Rules or assumptions Metacognition (e.g. ‘if I struggle hard enough I can get rid of these voices, they are controllable’, or ‘bad people have bad thoughts’)

Emotions with related body state Coping behaviour and relationship with voice (resistance versus engagement)

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et al. (2000a) validated a revised version, the Beliefs About Voices Questionnaire – Revised (BAVQ-R; Appendix), with a sample of 72 people with psychosis who experienced voices. The BAVQ-R uses a more sensitive fourpoint scoring for each item and more adequately assesses omnipotence. Where the BAVQ had but one item assessing this dimension, the BAVQ-R has six. The study further underlined the importance of the concept of omnipotence. Items assessing omnipotence were strongly endorsed: ‘My voice is very powerful’ (86%), ‘My voices seem to know everything about me’ (79%) and ‘I cannot control my voices’ (75%). In this study we sought to clarify use of the terms power and omnipotence, suggesting that power be seen as one aspect of the broader dimension of omnipotence. Symptomatic meaning linked with visions is formulated in the same way as with voices. While conceptually tactile and olfactory ‘hallucinations’ are also sensations and placed in the A column, it is important to note that they rarely have the immediate interpersonal quality of voices and visions.

ABC Formulation of Paranoia The past decade has seen the development of sophisticated and clinically useful cognitive theories of paranoia. There is insufficient space here to review these, but excellent analyses by Bentall (2003a, b) and Freeman and Garety (2004) are ideal starting points. Defining paranoia is complex. With apologies for the use of the word delusion, Chadwick et al. (1996) isolate planned harm by others as the key defining attribute: let us consider a man who believes that he is unpopular, that people in his office are talking about him and poking fun at him, and that they would like to get him to move office. Is the belief a paranoid delusion? At this stage no … What if our imaginary client goes on to say that he has noticed little signs in the office relating to him, such as a copy of a travel book left on a desk in order to give him a message to ‘travel’. This idea is paranoid in the everyday sense of the word, but do we yet have a paranoid delusion? The answer, we think, is still no. Individuals who are depressed or socially anxious commonly misinterpret everyday objects and behaviour in just this way … What if he goes on to say that he thinks they are hatching a plot; that is, not merely wishing that he would leave and maybe making his life uncomfortable, but conspiring to have him sacked … this would constitute a paranoid delusion. (p. 141)

In keeping with a focus on distress, it is important to recognise that the key emotion with paranoia is fear – clients experiencing paranoia are first and foremost fearful of harm to themselves, or others, or both. We find it helpful to think of paranoia as an evolved trait that was selected and distributed within humans because of its adaptive value (Ellett, Lopes & Chadwick, 2003). There is growing evidence that paranoia is common in everyday life (e.g. Ellett et al., 2003; Fenigstein & Vanable,

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1992; Martin & Penn, 2001). Of course, there is a danger of assuming that any human behaviour or trait that is reasonably common is necessarily adaptive – a logical error known as the naturalistic fallacy (e.g. Sedikides & Skowronski, 1997). Yet paranoia is a promising trait to consider from an evolutionary perspective. It is first and foremost a perception of interpersonal threat to self – this is an ecologically important problem, which is one of the key issues in evolutionary psychology when considering why a trait might undergo natural selection (Sedikides & Skowronski, 1997, p. 80). Clients themselves routinely isolate the main advantage of paranoia as keeping them safe from harm, and important research is shedding light on links between safety behaviours and paranoia (Freeman & Garety, 1999; Freeman, Garety & Kuipers, 2001). Again, paranoia has the properties of what Gilbert (1992) calls the defence system. In this state, affect is strong, cognition is narrow, attention is threat-focused, and the body gears up for fight or flight. Contemplating an evolutionary perspective helps therapists appreciate the compelling force of paranoia for clients. In keeping with the ZoPD framework, it is helpful to distinguish symptomatic and schematic paranoia. Symptomatic Paranoia Symptomatic paranoia refers to a person’s specific persecutory beliefs, and has a number of key attributes. First, symptomatic paranoia is most likely to occur under environmental conditions (i.e. A) associated with high selfawareness (e.g. Fenigstein & Vanable, 1992) and presence of psychological or physical threat (Bentall, 2003a, b), or at least ambiguity or uncertainty. Second, fear is the key emotion (C), with a powerful physical dimension. Third, linked to this emotion, there are associated safety behaviours (see Freeman et al., 2001). Fourth, within cognition (i.e. B column), symptomatic paranoia expresses an external personal attribution (Bentall, 2003a, b) for the unwanted A. Fifth, while intention to harm is definitional of paranoia (see above, and also Freeman & Garety, 2000), Trower and Chadwick (1995) have argued that this imputed malevolence can be perceived as either an undeserved persecution (Poor Me) or a deserved punishment (Bad Me). Chadwick et al. (1996, chapter 8) discuss in detail differences in assessment and therapy for distressing Poor Me and Bad Me paranoia. Schematic Paranoia In Bad Me paranoia, NSS are conscious; clients feel that they deserve others’ malevolence, because of their own badness. When Poor Me paranoia dominates awareness, it is negative schemata of others, not the self, which are conscious; clients feel that others’ malevolence is undeserved. In both Poor Me and Bad Me paranoia, the basic perception of self as different

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occurs. If a client feels fundamentally different from others in a negative way (e.g. perverted), this supports Bad Me paranoia, whereas if the difference has a positive valence, this supports Poor Me paranoia, perhaps with a grandiose flavour (e.g. there is a conspiracy to prevent a client achieving something momentous). Others tend to be perceived as powerful and malevolent in both experiences of paranoia. Schematic paranoia is a generalised fear of harm by others driven by enduring underlying rules (e.g. ‘If you show people any vulnerability, they will harm you’ or ‘If you get close to people, they will betray you’). Clinically it is striking how, for many clients, schematic paranoia develops in childhood or adolescence, many years earlier than specific symptomatic paranoid beliefs. Schematic paranoia is learned in response to life events, usually traumatic. While people can feel traumatised by objectively abusive or terrifying experiences (e.g. sexual or physical abuse, bullying or a serious car crash), from a cognitive perspective trauma is an emotional state (i.e. a C), and not a life event (A). People can thus feel traumatised in situations that might objectively appear not to be traumatic. One woman grew up in a small house where the door to the staircase to the first floor opened straight into the only downstairs sitting-room. Her mother held regular gatherings of her female friends in this room. As a self-conscious teenager the client felt acutely distressed each time she had to pass through a gathering to go up or downstairs – the comments from those gathered were never rude or hostile, though were occasionally a little insensitive.

RELATIONSHIP: A MINDFULNESS-BASED FORMULATION OF DISTRESS Mindfulness has a very clear relational understanding of distress, which is shown in Figure 3.1. In the face of an unpleasant psychotic sensation (voice, paranoid thought, image, etc.), distress results from an absence of clear awareness of what is being experienced because a person is lost in reacting to it. In particular, we have focused on three main reactions – these are that a person is lost in experiential avoidance, negative judgement (of the sensation or self or both) and rumination/confrontation (Chadwick, Newman Taylor & Abba, 2005). Experiential avoidance is defined as occurring when a person is unwilling to remain in contact with sensations (e.g. thoughts) and takes steps to alter the form or frequency of those events and the contexts that occasion them (Hayes, 1994). In psychosis, judgement of psychotic sensations is very often of a perceived ‘other’ – that is, a voice or a persecutor. We link rumination and confrontation because both express resistance (Chadwick & Birchwood, 1995) of the ‘other’. Underpinning these reactions is an assumption that the ‘self’ (which is reified) is defined by these experiences and how one reacts to them. There is empirical evidence that people with psychosis react to voices (Birchwood & Chadwick, 1997) and paranoia (Freeman & Garety, 2004) in these ways.

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Figure 3.1 A mindfulness-based understanding of how relationship with unpleasant sensations mediates distress or well-being. © Cambridge University Press. Reprinted with permission

So, in the face of a derogatory voice saying ‘you are useless, you should kill yourself’, a person might attempt to avoid the experience through listening to music through headphones or drinking excessive alcohol, might judge the voice as evil and himself as bad and worthless, and might get lost in a depressive rumination on hopelessness and suicide. The right-hand side of Figure 3.1 is a relational conceptualisation of moment-by-moment negative self-schematic experience. In direct contrast, responding mindfully to unpleasant psychotic sensations is to maintain decentred awareness while being open and receptive to whatever is sensed without reacting to it, or identifying with it. The left-hand side thus conceptualises in relational terms a moment-by-moment Rogerian acceptance of experience and self: a ‘letting of material come into awareness, without any attempt to own it as part of the self, or to relate it to other material held in consciousness’ (Rogers, 1961, p. 78). Here, while psychotic sensations experienced mindfully likely remain unpleasant, or painful, the distress (or suffering) that comes from reacting against them is absent. In Chapter 1, when describing the broad conceptual integration of mindfulness and CT, both meaning and relationship were defined as cognitive mediation (B) within the ABC framework. In practice, for shared formulations, the ABC framework is used for analysis of symptomatic meaning only, and Figure 3.1 to formulate relationship with unpleasant psychotic sensations. While there are implicit beliefs and rules tied to experiential avoidance, judgement and rumination (see Chapter 1) to draw these out within an ABC formulation takes the emphasis away from relationship and on to meaning, which is to lose the unique contribution of a mindfulnessbased formulation of how relationship creates distress.

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FORMULATING NEGATIVE AND POSITIVE SELF SCHEMATA The third formulation within PBCT is formulation of schemata, both positive and negative. Schematic beliefs are routinely included in an ABC formulation. Nevertheless, there is considerable value in formulating them in their own right. They represent a powerful source of distress and clients find it very helpful to have a clear written understanding of them. Figure 3.2 shows formulations of the NSS and PSS elaborated in the

Others: Judgmental, dangerous, malevolent, superior Self-self and Other-self: I am totally worthless, bad, this can never change Future: Dangerous, lonely, cannot fundamentally change Experience of body: Slumped, fat, ugly, avoid eye contact

RULES However hard I try, I’ll never be able to do anything of value If I try to do something, it will always be rubbish If people have a chance, they will harm / destroy me Behavioural strategy: avoid people, challenges and self-expression

Situation In company and voice began (‘she’s bad, there’s nothing good left in her, she’s useless, worthless, this is all she is’)

Figure 3.2(a)

Thoughts I’ll be judged or attacked for the slightest thing. Whatever I say or do won’t be any good Body Physically sick Rocking, fiddle and fidget Slump

Negative self schemata (NSS)

Feelings Very sad Depressed Frightened

Behaviour Don’t try to say or do anything, avoid people, isolate self

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Self-self: I am worthwhile, I have something to offer, I have good left in me. I am of equal value to others Others: Accepting, helpful and interested in me Other-self: Others see me as equal Experience of body: Upright, speech more coherent, smiling, more at ease physically Future: I can feel safer and more connected with others

RULES If I am vulnerable, people will accept and want to help me If I am able to engage with people, I have things of value to contribute Behaviour: cautious approach and engagement with certain people

Situation Church meeting, ‘each person saying their bit’

Figure 3.2(b)

Thoughts Others see me as able to hold a proper conversation. I have something to offer people Body Smiling More comfortable More settled

Feelings Nice Really good

Behaviour Took risk – stayed and expressed my views Made eye contact

Positive self schemata (PSS)

two-chair transcript in Chapter 7, using a formulation of schemata developed by Kennerly (Working with Schemata Workshop. Southampton University, 1997). Within PBCT formulating positive and negative schemata harmonises with the two-chair methods described later for working with schemata. Also, the fact that the positive and negative experiences of self are formulated using identical diagrams supports metacognitive

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understanding that the symbolic self comprises complex and contradictory experiences. It is useful to ask: what is the difference between formulation of a schema, and a traditional Beckian developmental diagram? First and foremost, formulating a schema does not go beyond what is presently experienced. Everything depicted in Figure 3.2 is experienced and open to awareness in that moment, giving the formulation a powerful phenomenological basis. A developmental diagram goes beyond current experience by including Early Experience and events inferred to have triggered a current ‘episode’. It is often when attempting to make these inferred links to life events that developmental formulation of psychosis breaks down (see below).

BECKIAN DEVELOPMENTAL DIAGRAMS Traditionally in CT case formulation has involved a developmental diagram. This is usually a variation of a Beckian developmental (sometimes called longitudinal) diagram, which involves Early Experience, Schemata, Rules (with linked behaviour), a trigger for a current ‘episode’ and a hereand-now analysis of situation(s) involving distressing thoughts, feelings, behaviour and body state. There are certain clients for whom it has been helpful to place current distress in a historical context using a developmental diagram – often people with a traumatic history. Yet there are conceptual and practical problems with developmental diagrams that mean they are rarely used in PBCT. From a theoretical perspective, there are concerns over the validity of developmental case formulations. This is true even for depression (Bieling & Kuyken, 2003), where the cognitive model is on its firmest ground. It would be ironic if the concept of schizophrenia were abandoned as invalid only to be replaced by an alternative conceptual framework that also lacked validity. Beckian developmental diagrams are also problem focused (e.g. there is no positive self schema) and traditionally are closed systems – it is not apparent how to break out. Also, to clients the use of boxes and arrows can appear linear and causal; yet it would be misleading and psychologically simplistic to imply that a trauma aged eight years old in any sense ‘caused’ the emergence of voices or depression some years later. There are also substantial practical problems with developmental diagrams. Our research (Chadwick, Williams & Mackenzie, 2003; MorbergPain, Chadwick & Abba, 2006) involving 30 people with distressing psychosis showed that clients give diagrams meaning, which can be positive (e.g. it helps to feel understood) or distressing and negative (e.g. if my problems go all the way back to these early experiences, then they can never be changed). Of course it is strong negative emotional reactions to

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case formulations (CF) that are most concerning – for example, sadness is an appropriate reaction to being reminded of current and historical suffering. Yet the CF literature has been comparatively silent about negative impact for clients. Our research even suggests that CF is a point of possible therapist–client distance – a positive experience for the former but not latter (Chadwick et al., 2003). This raises the provocative idea that at least some of the faith therapists have in the potency of CF might be due to the positive impact it has for them personally. There is also a fundamental problem using developmental diagrams for distressing psychosis – clients’ experience does not always fit neatly into such a diagram. It is common to find clients for whom there are no neat and easy links between current distress and early experience. These are the times when therapists have a sense of trying to fix a model onto a person, rather than being truly collaborative and seeking to explore and understand a person’s experience. Therapists know when this balance is lost. They feel frustrated by the lack of fit with a diagram, they have a growing sense of unease about the formulation process, and they feel a sense of trying to locate experiences in the person’s past so as to complete a diagram. When this is happening it is better to formulate in other ways. One main stumbling block seems to arise from trying to force together into one linear progression formulation of current distressing psychosis with developmental origins of NSS. This is not to say that a theoretical link does not exist, but the key point is that we do not have to have the entire picture. It is sufficient for the majority of clients to have separate formulations of schemata and symptomatic meaning, with a formulation letter to provide overall coherence. The problem for many therapists is their assumption that a developmental diagram is the bridge between assessment and treatment, and that they cannot intervene adequately until they have one – another therapist should that threatens collaboration, one that echoes a medical diagnostic approach. In contrast to this view, we would argue that what is necessary to intervene is an understanding of current sources of distress. This may or may not usefully be supplemented by links to common formative (not necessarily early) experience. I have found developmental diagrams to be useful in groups, when I have wanted to develop a general formulation of the group’s distress. That is, not an individual CF, but a formulation completed at a level of abstraction that allows all clients to find common experience. In a group for people with distressing paranoia, the formulation shown in Figure 3.3 unfolded week by week, beginning with current experience and working backwards in time. This process supported universality well, while incorporating individual differences – for example, all people recognised how their paranoia had environmental triggers, yet for one person this was being alone where for another it was being with people. It is important to recognise that each individual’s specific paranoid belief is not described.

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Formative experience Traumatic event and emotions, involving feeling different and ‘singled out’

Core beliefs I am different; I am bad, or others see me as bad Other people are uncaring, malevolent Things will not change, it won’t get better

Rules and linked interpersonal behaviour If bad things happen, I am responsible and to blame Other people cannot be trusted If people see your vulnerability, they will harm you and take advantage Avoidance of others, lost ability to communicate. Hide ‘difference’

Triggers Negative, painful, stressful or disturbing life events

Situation Nightmares, Alone, crowds …

Thoughts

Feelings

I am different Things/people refer to me; I am being watched, followed, I’m in danger I might be attacked/killed

Fear, anxiety, horror, depression, ‘crowded’, lonely, guilty

Behaviour Avoid people. Get away, escape fast Pacing up and down Distract, use coping strategies

Figure 3.3

Physical signs Breathless, heart pounds, sweating Palpitations Tingle in fingers Adrenaline rush

Cognitive therapy understanding of group’s experience of paranoia

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CONCLUSION ON THE CONTEXT IN PBCT In the opening three chapters of this volume we have spelt out the therapeutic context in PBCT. Chapter 1 elaborates the origins of PBCT, together with its primary influences. Chapter 2 argues for the practice of radical collaboration – that is, building a relationship that is free from therapists’ anti-collaborative beliefs and assumptions about how therapy should progress. Chapter 3 presents an original framework for therapy, the ZoPD with its four related sources of distress and well-being – symptomatic meaning, relationship with internal experience, schemata and the symbolic self – and explores how this is supported by case formulation methods.

Chapter 4

WORKING WITH SYMPTOMATIC MEANING

OVERVIEW In the move to broaden cognitive therapies to embrace acceptance-based interventions, it is important not to undervalue work with symptomatic meaning, or what is sometimes called ‘content’. In PBCT it is one of the four domains of the ZoPD and remains a vital part of therapy. Exploring the domain of symptomatic meaning is to explore collaboratively a person’s capacity to step back from fixed belief systems, to observe how they generate distress and disturb behaviour, and to create new meaning that supports well-being. The key skills when working with meaning are to explore goodness of fit of beliefs, embrace doubt and uncertainty, think creatively and flexibly, assess usefulness and impact, and plan and carry out behavioural tests. The aim is not to make people change; it is collaboratively to explore proximal development.

PRACTICAL STEPS FOR WORKING WITH SYMPTOMATIC MEANING CBT traditionally has used two main approaches to changing meaning, symptomatic and schematic. Symptomatic meaning includes the traditional examination of evidence for and against the belief (‘goodness of fit’ with experience), exploration of its usefulness (impact, and advantages and disadvantages) and metacognitive interventions, mostly about cognition–emotion links. The schematic level includes schemata, rules and metacognitions about the nature of self, and is assessed by exploring the implications of symptomatic meaning. The former is traditionally assessed by asking, ‘What is the evidence?’ The latter is traditionally assessed by assuming for a moment that the feared symptomatic meaning occurred, and asking, ‘What would be so bad about that?’ If a client feared failing an exam, exploration of schematic meaning might be assessed by saying, ‘Just for a moment imagine that you did fail the exam, how would you

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feel, what would it say about you as a person?’ Within PBCT working with schemata is a distinct domain of the ZoPD, and has a dedicated chapter. When working with symptomatic meaning it is helpful to have three points in mind. First, many clients have not articulated and thought through their beliefs in detail, especially ‘around the edges’, even after years – something that is quite normal. Second, for many people belief change is more about a chink of light than a paradigm shift. Third, all methods discussed in this chapter directly support proximal development. Therapists often do not see methods such as exploring doubt or sharing the ABC model as active change methods, but rather as paving the way for the telling interventions. They ask in supervision, ‘When do we start intervening?’ This is a very unhelpful perspective. If you share the ABC model or explore doubt with clear conceptual purpose, this is just as much an intervention as a behavioural experiment.

ABC ASSESSMENT OF SYMPTOMATIC MEANING A thorough ABC assessment is a powerful way not only of eliciting symptomatic meaning, but also of imparting important metacognitive insight. In particular it illuminates: (1) how all experience constitutes common distinct components (sensations, cognitive reactions, emotions, behaviour, body state), which with practice can be distinguished, (2) how symptomatic meaning is both reaction to and attempt to make sense of situations, life events and sensations (As), (3) establishing how clients’ problems can be understood in terms of distress and disturbance (Cs), (4) showing how meaning mediates distress, and in specific ways (i.e. specific B–C connections, such as anxiety going with catastrophic thoughts about the future and behavioural avoidance), (5) how meaning is never immutable and can be worked with deliberately to reduce distress and enhance emotional well-being. An ABC formulation is a way of organising a client’s experience in a way that is useful and easily understood by clients, staff and carers. The ABC framework can be used in formal assessment, although often therapists can simply hold it in mind to guide discussion, or conceptualise a difficulty in therapy. In brief, completing an ABC assessment of voices or symptomatic beliefs involves the following steps (we describe the process fully in Chadwick et al., 1996, especially chapters 3 and 5): (1) Isolate a specific (recent) situation or time when distress was high. (2) Draw out the context or situation (A) in detail, separating As and Bs. (3) Draw out, define and rate distress, with behavioural urge and action, and body state. (4) Agree to spend time focusing on understanding sources of this distress.

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(5) Reflect back and draw out surface thoughts and images (‘what was going through your mind when you were feeling …’). (6) Begin thought chaining (‘downward arrow’) and draw out symptomatic meaning. (7) Draw out schematic meaning, beginning usually with other-self schema and then moving to self schemata and also self-other schemata. (8) Link B and C throughout. (9) Consider the assumption or rule that might be ‘written in the person’s behaviour’. (10) Ask person to talk you through their understanding of the ABC Formulation.

Common Practical Difficulties ABC formulation is a skill for therapist and client. It is important to be radically collaborative throughout, rather than striving to achieve a goal (e.g. ‘downward arrow to a core belief’). An ABC assessment can take two or even three sittings to complete. Problems often arise because therapists have not narrowed down to a specific situation (A) and are trying to assess from a general description (‘I have been feeling bad all week’). Another common problem is not defining an emotion and checking that distress was high (e.g. depressed, anxious) and therefore cognitively mediated, rather than mild (e.g. sad, concerned). Asking clients to rate distress subjectively helps ensure this, as well as revealing any tendency to minimise distress. A further common difficulty is to lose focus, and follow new connections – for example, when a client says, ‘This reminds me of a time in town when I thought I was being followed, I was terrified.’ It is important at step 4 in the above 10-step sequence to anticipate this and establish how you will retain focus: ‘I’d like us to spend some time understanding your distress in that situation, is that okay? We may need to discipline ourselves not to get distracted or drift off the point. Writing this out as we go might help. If I think we are drifting onto something else, I’ll tell you, and if you catch me moving away from your experience at that time, please tell me.’ Other potentially important experiences can be bookmarked for subsequent exploration. While PBCT emphasises distress, it is important to draw out behavioural urges and actions, and bodily states – these are often overlooked. Another challenge is that often an ABC formulation throws up two or more strong emotions. It is most helpful to look at each separately. Again, therapists often struggle to move from symptomatic meaning to schemata. I recommend a specific sequence for this, which is first to explore other-self schemata, and then self schemata. A typical dialogue might be:

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T: David, you were feeling very anxious, experiencing those men as watching and discussing you. At that moment how did they seem to view you as a person? D: What do you mean? T: (Pause) In that moment when you experienced them as watching you, did it seem like they were judging you at all? D: Yes, as bad. T: As bad. Did that seem like it was a judgement of a bit of you, or you as a person, the whole of you? D: The whole of me. T: How did you feel at the moment when you felt judged? D: Bad, very bad. T: So when you noticed the men, you felt anxious and experienced them as watching you. You felt judged and emotionally very bad. When you felt that you were being judged by them as bad, how was your self-esteem? D: Not very good at all. T: You felt negatively about yourself, you were judging yourself? D: Yes, I felt I am bad. T: So, you experienced yourself as bad. You as a person, or a part of you? D: Me, who I am. In the above dialogue the key steps are drawing out first the other-self schema, and second the self-self schema. It is crucial to ground both in emotion – this is why the therapist goes back to the affect having got the other-self schema. The client feeling ‘very bad’ when experiencing an other-self schema suggests that there is an NSS actuated (a Bad Me reaction: Chapter 3). Drawing out underlying rules is another common stumbling block. Our approach is to draw them out through the schemata, and by embracing their interpersonal quality: ‘What is it like, John, to be with other people when you experience yourself in that way?’ The process of eliciting both positive and negative schemata and rules is illustrated in a verbatim transcript in Chapter 6.

Separating Sensations and Meaning Cognitions that are emotionally hot have a kind of self-evident experiential quality for us all, at least while the emotions are running high, which gives them a felt sense of being facts of experience. It is crucial for clients to understand that symptomatic meaning and schemata are constructions of a complex and ambiguous world, not facts. This step can be very challenging for many clients (see Chapter 6 on Schemata). It is helpful first to try to establish that they are beliefs, leaving any discussion of their value or accuracy until later. What helps this is to see how within the

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ABC framework symptomatic beliefs are understandable reactions to and ways of making sense of certain experience (see Chadwick & Lowe, 1990; Maher, 1988).

GOODNESS OF FIT (‘EVIDENCE’) People are first and foremost meaning makers. Goodness of fit concerns the question of how adequately a belief makes sense of a person’s experience. It is vital when using supported discovery individually or in groups to begin gathering reasons people have for believing something, and only subsequently to examine aspects of people’s experience where beliefs fit less well. It has always been an assumption in our work that symptomatic meaning will fit with and make sense of certain key life experiences (Chadwick & Lowe, 1990). My view is that people invariably have grounds for their beliefs, and I communicate this. Embracing a person’s evidence for a belief makes apparent that it is not ‘irrational’ but understandable and grounded in hard emotional experience. Also, the starting point for proximal development is to understand a person’s experience as fully as possible, and this includes understanding evidence. Of course, not every piece of confirmatory experience needs to be documented. Rather it is more helpful to cluster evidence into categories, and have one or two examples of each. If therapists are in anti-collaborative mode (see Chapter 2), there will be a tendency to want to minimise evidence for a belief, precipitously challenge evidence or overstate counter-evidence.

Exploring Doubt Goodness of fit is about using supported discovery to explore the degree to which symptomatic beliefs fit with the entirety of a client’s own experience. The importance of this cannot be overstated. It is about helping clients to explore the edges of their belief system, to bring into awareness those aspects of experience which do not fit well with the belief, to recognise internal inconsistencies, and so on. At times of high arousal we all lose cognitive balance. Information processing becomes narrowed and prone to Beck et al.’s (1979) distortions of perception – arbitrary inference (jumping to conclusions), over-generalisation, personalisation, etc. Many clients experience distress precisely because they cling to beliefs about themselves that do not reflect the entirety of their experience (Rogers, 1961). At no point is a person being told what to think, or how to think. When beginning to explore a person’s capacity for doubt, we apply a standard seven-point sequence that checks for flexibility, and perhaps assesses openness to proximal development (Chadwick & Lowe, 1994):

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(1) Summarise belief and check understanding with person. (2) Check current conviction. (Do you currently have any doubts about this?). (3) Draw out any past doubt. (Has there ever been a time in the past that you have doubted this, even for a short while?) (4) Draw out emotions and behaviour that went with doubt (i.e. doubt is a B within ABC framework). It is important to know how the person feels and behaves when doubting the belief. (5) Ask person to come up with a hypothetical contradiction (Brett-Jones, Garety & Hemsley, 1987) Are you able to think of anything that would make you doubt this? What would have to happen today for you to doubt this? What about in the future? (6) Pose a hypothetical contradiction that you generate. Keep it simple. Offer it tentatively and speculatively. It would be an event which if it happened would appear to contradict the belief. (7) Summarise this process: ‘John, at the moment you clearly experience the paranoia as a fact, something which could not be false. It sounds like once in the past you doubted it when you got a job. You felt quite happy then. Other than that you’ve never doubted it, and can’t imagine ever doubting it. Is that right?’ Goodness of fit is neither with the therapist’s viewpoint, nor with ‘reality’ (we all inhabit a world of appearances: Chapter 1). However, adopting this position does not mean that anything goes, and that all views have an equal goodness of fit. If someone tells you that he would ride his bicycle on the flat at 300 miles an hour, were it not for the speed limit, you are not forced to embrace this idea just because you do not feel you have access to ultimate reality. Within the world of appearances people are trying to find robust ways of making sense of themselves and their world, and social consensus is a reasonably reliable measure of the robustness of our approximations to reality, as is a broad-based, open review of evidence.

Giving a Balanced Summary of Goodness of Fit Anti-collaborative assumptions about how therapy should progress (see Chapter 2) can lead therapists to slant a summary in favour of evidence against a symptomatic belief. This can be by overly stressing counterevidence, or minimising evidence for the belief, or both. This is picked up on by clients, who might well infer that a therapist wants to control them (change minds) or has not listened.

GENERATING ALTERNATIVE SYMPTOMATIC MEANING Generating alternatives to symptomatic meaning is a standard CBT method. It can be done either at the level of an overall belief, or for a specific

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inference or attribution within an ABC assessment. In PBCT, symptomatic alternatives to a belief system are more important than alternatives to specific attributions. A client who hears two men laughing in a pub might draw a specific attribution that they were laughing at him because they read his thoughts and knew about a past humiliation. With encouragement, the client will no doubt generate alternatives – perhaps the men laughed at a joke, or something on the television in the corner. Generating alternatives to specific attributions is unlikely to weaken conviction in a symptomatic belief. It is more likely to help clients decentre and recognise that attributions are beliefs (Bs) not facts (As), and to help them practise cognitive elasticity. Imagine a client with a symptomatic belief that his family is conspiring against him in a range of complex ways. An alternative symptomatic belief could be either an entirely different belief (e.g. my parents love me and are trying to help me get my life back on track), or a modification of the symptomatic belief (e.g. although I am sure they once tried to harm me, by taking me to hospital against my wishes, this does not mean that they always want to harm me). The symptomatic belief and alternative are assessed in the light of the available evidence (goodness of fit). It is important to encourage clients to make a case for both alternatives. So, for example, a dialogue might be: T: How does your family’s behaviour at the weekend fit with the idea of the conspiracy? C: It means they are lying to me – they know what’s happening, but won’t admit it. T: And how might their behaviour fit with the alternative, that they have made mistakes in the past, but do not intend you harm. C: It means they would be telling the truth. T: Just thinking about them for a moment, which is more likely – that they are lying to you, or telling the truth? C: I don’t know. T: Okay, so you are unsure about that – you could see it either way. Your family’s behaviour could fit with either belief. For voices, a symptomatic alternative to the belief system is always based around the perspective that voices originate from the person’s own mind, and perhaps reflect important personal themes from the past. Ideally this type of symptomatic alternative comes from earlier analysis of doubt: Jane, when we discussed whether you had ever doubted your beliefs, you said you did two years ago. Following a disappointment, for a few days you wondered if the voices might be just empty thoughts. I think this is important because it shows that you have different ways of making sense of the voices – either there really are powerful spirits controlling your life telepathically, or they are generated somehow by your own mind, in ways that we cannot fully explain.

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If no alternative emerges from investigating doubt, we offer one in a straightforward way: ‘It seems to me that there are only really two possibilities. The voices either really are other people communicating with you or they originate from your own mind, in a way we don’t fully understand. Can you see any other possible ways of making sense of what is happening?’ With voices it is important to be clear that the alternative is not an account of why the person hears voices – this would be an attempt to explain the A within the ABC model. PBCT is not based in a theory for the emergence of psychosis, and I am quite open with clients that in my view there is no satisfactory explanation for the emergence of voices. If a person comes up with an alternative and adds ‘But I know it’s not right’ accept this, and feel free to continue supported discovery, perhaps saying ‘Yes, it’s not easy to even think of alternatives to important beliefs. I like that alternative, it’s plausible – and what makes you so sure it is impossible?’

ESTABLISHING A METACOGNITIVE ALTERNATIVE As metacognition has become more clearly defined within CT, I have come to appreciate and embrace just how many methods described in our CT for psychosis (Chadwick et al., 1996) were intended to promote metacognitive insight, rather than simply weaken belief conviction. What this means is that those methods had at that time as a clearly stated aim to encourage understanding of one or more cognitive processes concerning symptomatic beliefs or voices. The most important of these interventions was to establish a metacognitive alternative to the client’s symptomatic belief. This was always based in metacognitive insight into the experiential basis and function of symptomatic beliefs. As Chadwick and Lowe (1994, p. 357) stated, ‘following Maher, an alternative perspective was offered, namely that the belief was formed in response to, and as a way of making sense of, specific experience – often this included a primary symptom, but in several cases it was hypothesized that the belief was formed in response to important life events’. An important aspect of this metacognitive intervention is the portrayal of symptomatic beliefs as reasonable – that is, they are grounded in experience. This point is communicated during ABC assessment. We viewed so-called cognitive biases such as jumping to conclusions as indicative of emotional reasoning (i.e. driven by affect) rather than peculiarities of general reasoning in people with psychosis (Chadwick et al., 1996). A second linked metacognitive intervention concerned the regulatory impact of symptomatic beliefs – that they, like all strongly held beliefs, are self-maintaining because they regulate perception, emotion and behaviour. As Chadwick and Lowe (1994) stated, symptomatic beliefs ‘like other beliefs, alter our relation to the environment, because they organize

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and structure future experience … a belief’s regulatory potency does not hinge on its accuracy, nor on the degree to which it is the result of reason, nor on its adaptive value’ (p. 356). Again, we stated an ‘integral part’ of the verbal challenging of symptomatic beliefs ‘involved the therapist making clear to individuals how strongly held beliefs can exert a profound influence over their behaviour and interpretation of events’ (Chadwick & Lowe, 1994, p. 357). This concerns metacognitive insight into the impact of symptomatic beliefs. Recognising the regulatory function of beliefs lessens the likelihood of clients blaming themselves for having held beliefs for too long. We have always been at pains to stress how all strongly held beliefs are self-maintaining, as verbal self-regulation of behaviour gears people cognitively and behaviourally for confirmation (Chadwick & Lowe, 1990). With voices, a metacognitive alternative is that a person’s beliefs about the voices are reactions to and attempts to make sense of this powerful experience. It is not an attempt to explain why they hear voices. A metacognitive perspective encourages clients to step back and view the beliefs they formed about voices as attempts to make sense of this startling experience. This metacognitive alternative complements a symptomatic alternative for voices (see above).

SYMPTOMATIC MEANING AND INTERPERSONAL RELATIONSHIP WITH VOICES An important study by Benjamin (1989) first established the interpersonal nature of clients’ relationships with their voices. There is growing interest in working more directly with clients’ interpersonal relationships with their voices (e.g. Birchwood, Meaden, Trower, Gilbert & Plaistow, 2000; Hayward, 2003). This extends those aspects of our cognitive model of voices which are explicitly interpersonal, namely omnipotence, resistance and engagement (Chadwick & Birchwood, 1994, 1995). We argued that work with voices needs early on to address these interpersonal issues of omnipotence, and involve a ‘change in relationship with voices’ (Chadwick et al., 1996, p. 95). To this end, we have developed a groupbased CT to challenge the omnipotence of voices (Chadwick, Sambrooke, Rasch & Davies, 2000b). Working with relationship supports proximal development in symptomatic and metacognitive meaning – and can also be used to address schematic meaning (see the section on experiential role-plays with voices, Chapter 6). Mark Haywood and I are exploring further therapeutic ways of working directly with interpersonal relationship with distressing malevolent voices, and especially aspects of omnipotence, including the interpersonal balance of power and control. An empty-chair technique offers an

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experiential way of working with interpersonal relationship. Empty-chair work differs from two-chair work (see Chapters 6 and 7), though both rely on supported discovery. A client’s voice is located in a second, empty chair. The client remains in the first chair, and there is no attempt to have a two-way dialogue with voices, as can occur in experiential role-plays with voices (see Chapter 6). • The relationship as it is now. The therapist and client discuss initially how the relationship is now, and the client is encouraged to do this by talking directly to the voice in the second chair – for example, ‘when you keep going on at me, I feel so frustrated and undermined’ or ‘you never say anything positive about me, which eats away at my selfesteem’. Any positive aspects of the relationship are also addressed: ‘I’m grateful sometimes when you warn me to be careful.’ Questions address directly the interpersonal relationship: ‘How do you experience your relationship with your voices? In what ways is it like other relationships? How is it different?’ While there is growing interest in similarities between aspects of clients’ relationships with voices and other significant people in their lives, past or present, it is striking how many clients say the overall relationship with voices is different from any other relationship. Questioning moves towards looking at interpersonal consequences of voices’ omnipotence. In what ways do clients avoid contact with voices? How does fear of the voices’ power alter what clients say to voices, or what they do in life? How do clients appease their voices? How does it feel to behave in these ways with voices? How are avoidance and lack of assertion manifest physically in clients’ body posture and tone of voice? Does the relationship with voices compromise important interpersonal standards? • How I would like to be in the relationship. Supported discovery then moves to how the client would like to be in the relationship – this is different from how the client would like the relationship to be. What are clients’ positive interpersonal rules about how they would like to relate to others, and how might these be expressed in relating with voices? Clients articulate and then express this directly to the empty chair. Therapists help clients take a graded exposure approach, beginning with statements that feel less risky, and monitoring how this felt. Therapists support clients to adopt a physical posture and tone of voice that suits a more assertive and balanced relationship with voices. Clients can express how they would like voices to be with them, which is another important aspect of balanced, assertive relationships: ‘I would like you to be more understanding and supportive and it disappoints me that you are not.’

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SHARING THE COGNITIVE MODEL Sharing the cognitive model is about decentred awareness of specific cognition–emotion links, plus metacognitive insight into the general way meaning creates distress, the defining feature of all CTs. It is better to share the cognitive model Socratically through a person’s own experience than it is to teach it. The cognitive model can be shared through ABC assessments of different emotional reactions to comparable sensations/situations. Examining the phenomenology of distressing experience through the ABC framework renders distress understandable in terms of meaning, showing how in a given situation specific emotions were associated with specific cognitions. An advantage of the ABC framework over, say, a Hot Cross Bun analysis is that meaning is situated between experience and distress, embodying this mediation. The simplest way to share the cognitive model through ABC assessments is to build upon preceding analysis of doubt and generation of a symptomatic alternative (see above) and draw out the linked emotions. In the above example with Jane, the intervention would be to draw out and reflect how her two ways of making sense of the same voices generated different feelings: ‘Jane, for those few days when the voices seemed just like empty thoughts you felt sad, a sense of loss, but also relieved that at least you could be more in control of your life. When you make sense of the same voices as powerful spirits, you feel frightened, angry, powerless and helpless – life loses a lot of meaning. What your experience shows is that it’s possible to make sense of the voices in different ways, and how you make sense of them determines how you feel. This link between how we make sense of things and how we feel is really important. Can you put this link into your own words?’ The cognitive model is counter-intuitive. The everyday language of distress reflects not a B–C cognitive mediational model, but an A–C model (e.g. I am happy because I get paid today, or I am depressed because I have lost my job, or I am too anxious to go to work because my boss criticised me yesterday). Therefore always therapists need to check clients’ understanding of the model, asking them to put in their own words what has been said. The model might need to be gone through several times, initially with a range of illustrations from a client’s experience and perhaps backed up by examples from a therapist’s own experience.

Imparting the Cognitive Model with Derogatory Voices Metacognitive insight into the cognition–emotion link can also be imparted through an adapted version of the standard Unicorn method (Trower et al., 1988). (This method can be linked with the experiential Socratic

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dialogue role-plays for voices described in Chapter 7.) I well remember what made me first use this method. A client made a passing remark that his voices ‘couldn’t call him unintelligent’. The remark made a strong impression on me, because I thought, well actually they could, and asked him why not. What became apparent was that he was saying: ‘I know I am very intelligent, they couldn’t get me to believe that I was stupid.’ The process is described below through a clinical example of a client whose voices told her repeatedly she was ‘ugly’, ‘fat’ and a ‘slag’ (which the client defined as meaning sexually immoral). Being called ugly distressed her considerably; being called ‘fat’ and ‘slag’ bothered her far less. Therapists need to gauge how much iteration is needed at each step, before progressing through the process. The process does not begin with the most distressing negative judgement – in this case, ‘ugly’. Rather, therapists use less distressing judgements that are still relevant and meaningful – in this case, ‘fat’ and ‘slag’. These can be found by checking the range of judgements voices make about a client, and the usual degree of distress attached to each. (1) Using the less distressing judgements, the client is asked to rate distress on a specific occasion: ‘Jane, you remember when the voices called you ‘‘slag’’ in today’s session. At that time how distressed did you feel on a scale of 1 to 10? In that moment, how much did you believe that this judgement applied to you?’ This is repeated either for times when conviction was very different or by imagining that conviction was very different: ‘Jane, has there been a time when you didn’t believe this judgement really described you as a person? At that time, how distressed did you feel?’ Or using the client’s imagination, a therapist might say: ‘If you believed what the voice said 100%, how would you feel? If you believed it 50%, how would you feel? If you completely rejected it, how would you feel?’ The client is asked what she makes of this process, and client and therapist collaboratively draw out the metacognitive insight that the same voice statement goes with differing degrees of distress dependent on changes in meaning – the B–C connection. (2) Having worked through step 1 with one or more examples that are mildly or moderately upsetting, the therapist moves to the sensitive issue(s). Initially this can be done with the client imagining a friend, or person (e.g. TV celebrity) who is not concerned about the sensitive issue. So in the present example, the client would be asked to think of a friend or person who feels attractive and happy with her appearance – or even two people, one who considers herself really beautiful, and another who is in the middle, neither ugly nor beautiful. The same Socratic questioning as in step 1 then takes place, to show how an insult does not have to produce the same emotional reaction in all people. The precise emotion depends on how that person feels in relation to the issue.

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(3) Only now is the hot cognition addressed. The client considers how distressed she herself feels when the voice calls her ugly. Again, the therapist looks for different levels of distress at different times, and links this to meaning. The client is encouraged to step back from the process, and articulate the connection between her emotions and her self-judgements. (4) The process is summarised by therapist and then client. Including the standard Unicorn example at this point makes the metacognitive insight more easily remembered: ‘Jane, what we’ve seen is that voices cannot make you believe just anything about yourself. If they told you that you were a unicorn, you wouldn’t believe them. They aren’t that powerful. What they tend to do is feed off your own fears and lack of self-acceptance. When they call you ‘‘slag’’ or ‘‘fat’’ it usually doesn’t distress you much, because you don’t believe these judgements. When they call you ‘‘ugly’’ it usually distresses you because you believe this judgement. It’s your self-esteem, your degree of self-acceptance that seems to determine whether you feel distressed.’ This process can be further strengthened by determining if the negative self-judgement (which might or might not be a full or negative self schema) predated the onset of voices. This is often the case, which further demonstrates in a historical way that the voices (i.e. the A) do not create the distress. Also, this shows that the voices did not create the negative self-judgement, which challenges further their omnipotence (Chadwick & Birchwood, 1994): ‘So, Jane, what you are saying is that you were feeling depressed and judged yourself as ugly long before the voices first began. It is almost like the voices follow what you think, even though it feels the other way around. What do you think about that idea?’

USEFULNESS: ADVANTAGES AND DISADVANTAGES The client’s symptomatic belief and symptomatic alternative are evaluated not only in terms of goodness of fit, but equally importantly in terms of usefulness. Usefulness is about advantages and disadvantages; it is about impact on daily life. Impact of distressing psychosis reaches all areas of life – major life changes (losing family, friends, job), day-to-day hassles (a man who could no longer go swimming because of his voices), and psychological changes (low self-esteem, depression). In one group for people with distressing paranoia the five members described the impact of paranoia as ‘like living in a prison’. They reported: avoiding going out, enjoying things less, feeling stressed and withdrawn, feeling misunderstood, struggling to take decisions, losing trust in others, coming to see others as uncaring or persecutory (conspiring to harm them), feeling fear and hostility towards others, feeling negative about themselves (as ‘different’,

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‘weird’, ‘not fitting in anywhere’, ‘ugly’, ‘unattractive’, ‘nuts’ or ‘mad’), losing religious faith, feeling confused about what was real or unreal, feeling unable to communicate with people (‘even parents’), wondering ‘why should these things happen to me?’, feeling less socially confident, and more shy, isolated and socially anxious. There was one main advantage concerning personal safety. Clients felt that paranoid thinking kept them safer because it let them be vigilant and avoid taking risks. A further advantage of paranoia for one man had been that it made him realise that he was ill and needed help. A substantial advantage of a symptomatic alternative is always that a person is free from danger of harm from persecutors or omnipotent voices. A person has greater scope for self-efficacy and emotional wellbeing. Possible disadvantages of the symptomatic alternative are that (1) people can feel responsible for the voice content (e.g. this means that I must want to harm my children), which comes from the metacognitive belief ‘sensations reveal my true self’, and (2) people might feel a sense of loss, of having ‘wasted years’ living according to an illusory belief.

CHOICE Therapists clarify that it is not their role to try to get rid of clients’ paranoia or voices. Relationships with voices, images and paranoid beliefs are complex, and these experiences are usually valued in some respects. What is important is that clients feel that therapists accept their right to continue investing time and energy in the ‘old’ belief. Also, it is important that clients feel that any proximal development based in the new meaning will be safe and collaborative. A therapist summary of this position might be: ‘John, it sounds as if the main advantage of paranoia is that it keeps you safe. You’ve been badly hurt by some key people in your life, and it feels important for you not to trust others again in case you are hurt again. But you’ve said the main disadvantage is that if you don’t trust anyone at all, then you don’t really live your life. You feel lonely, don’t go out, and life is empty and negative. This is a difficult position for you, deciding what to do. If you choose to hold onto these beliefs, that is your right – if you choose to explore other ways of making sense of your life and relating to others, then we can work together to do that as safely as possible.’

BEHAVIOURAL EXPERIMENTS Behavioural experiments (BEs) are so named because they test hypotheses. As Chadwick and Lowe (1994) stated, the main feature of such reality testing ‘involved the individual planning and performing an activity that

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could invalidate the belief or some part of it’ (p. 358). They are most effective when two distinct possible explanations have been established with clear and opposing predictions about the chosen experiment (Chadwick & Lowe, 1994). Their effectiveness depends on a client’s willingness to contemplate disconfirmation as well as confirmation, and a related opening of awareness to all experience, rather than an attentional search for confirmation. The major risks are either that the chosen task is unrealistic (i.e. unlikely to be completed), or that it is not actually a test of two opposing predictions. Also, there is always a possibility that a person will explain away any eventuality that challenges their belief. Tasks can be everyday ones – really noticing what happens when entering a supermarket, for example. The following sequence is used for behavioural experiment: (1) The process of identifying BEs begins with a clear rationale, which is linked to earlier discussion of impact and disadvantages. This might be: ‘John, it’s your choice if you want us to explore some ways of checking this out. From my point of view it feels important for us to be considering testing this belief because you are so scared by it, and it stops you going out much.’ (2) Ideally tests are generated by clients, or at least flow from earlier exploration of doubt. Helpful questions are: ‘What would have to happen today for you to doubt this belief?’ or ‘In that situation, is there anything those three men could have done that would make you think they were not spying on you?’ Replies to these questions form the basis of suitable tests only if they yield a meaningful and realistic possible alternative. (3) Therapists explore possible risks of any test. This can be supported by referring back to earlier ABC analysis of past doubt. In moments of past doubt, was there, for example, any associated depression or suicidality (Cs)? If so, what was the meaning that went with these Cs? Is anything different now? ‘John, you described feeling really low three years ago when you doubted this belief. If you doubted it today, how might you feel? Has anything changed?’ (4) Testing is more effective when the range of outcomes has been considered beforehand. This means drawing out clear predictions from the symptomatic belief and the alternative. Predictions need to be clearly recognisable. Ideally they would be observable behaviour, but they may, of course, be internal emotions – the key thing is that they can be noticed clearly and unambiguously. (5) ABC in imagination of the two possible outcomes offers some safeguard against the likelihood of explaining away disconfirmation of symptomatic predictions: ‘Okay, let’s just recap. If your father doesn’t lend you the money for a holiday, this would be consistent with the idea that he is monitoring you and doesn’t want you out of the

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country. Imagine that you have already asked him, and he gave you the money – if that happened, what might you feel, what would you conclude/think?’ (6) What is most likely to stop a client doing the test, for example, excessive fear on the day? It is important to explore likely reasons not only for avoiding an experiment altogether, but also for beginning and not completing one. Both risks need to be explored and problem solved. Therapists communicate that an untried or incomplete test will not jeopardise their acceptance of clients, while underlining the importance of trying to complete the planned BE. (7) Therapists reaffirm the rationale for the BE and the client’s freedom over whether to carry it out. This will have an added significance now that the precise test is known. Therapists check the person understands what is to be done and why: ‘It would really help me if you could tell me in your words what you are going to do, what the two possible outcomes are, and why you think we are considering carrying out this test/experiment.’ It is usually necessary to have something written down, stating the test and separating the two predictions, with a space for the client to record what happened at the time, how he felt, and what he learned from the test. An example is shown in Figure 4.1. BEHAVIOURAL EXPERIMENT FORM FOR TESTING BELIEFS Belief 1: (90% conviction)

Belief 2: Alternative (10% conviction)

My dad is monitoring me constantly and interfering in my life and trying to hold me back.

I find it very hard to trust my dad, who wants to help so much that he can get too involved in my life.

Prediction He will not lend me the money as he

Prediction He will lend me the money.

couldn’t monitor me on holiday. Agreed test I will ask my dad to lend me the money to go on holiday when he and I are alone at the weekend. Outcome He gave me the money as a gift. How I reacted at the time I felt close to him and trusted him. We had a nice evening together. Conviction in Belief 1 at time of test 20%

Conviction in Belief 2 at time of test 80%

Conviction in Belief 1 in session 50%

Conviction in Belief 2 in session 50%

Figure 4.1

Completed behavioural experiment form

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A note of caution is required regarding BEs. Most strongly held belief systems are ‘immunised’ against refutation (Popper, 1977). An individual test can have little or no impact, or its impact can be transient as a belief system adjusts to accommodate the apparent refutation (Chadwick & Lowe, 1990). Therapists can feel disappointed at such times if their hopes are unrealistic. An individual test needs to be viewed within the ZoPD as but one element of exploration of one of four domains. Rogers has a helpful phrase that is relevant here – he says ‘Facts are always friendly’. All consequences of a behavioural test are friendly, because they reveal something about a client’s potential for proximal development.

ACCEPT FIXITY When therapists encounter a belief that is fixed, it is helpful to bear in mind that Rogerian acceptance applies to all aspects of a person, including fixed beliefs. Fixity is informative – it says that at this point in time, there is no proximal development in terms of modifying conviction in the belief. Of course, the ZoPD is a process, which means that the situation may well change. For the time being, therapeutic energy is better directed to work in one of the other domains. A distinct advantage of the ZoPD is that it depicts how symptomatic beliefs are but one aspect of a client’s experience. And it is possible that proximal development in another domain, perhaps relationship, will through generalisation influence one or other dimension of symptomatic meaning.

THERAPIST CONVICTION IN SYMPTOMATIC MEANING It can engender humility in therapists to view symptomatic meaning as inferential (Chadwick et al., 1996) – that is, a belief that is logically possible. However, suspension of disbelief is not always possible, and is not crucial. Indeed, how would a CBT therapist work with panic disorder if she believed that a panic attack really might lead to death, or with anorexia if she believed that a client weighing five stone might actually be fat? What is crucial is to recognise and respect the way for the client the belief is real. This is the essence of Rogerian acceptance that a person’s feelings and attitudes and beliefs are ‘a real and vital part of him’ (Rogers, 1961, p. 21). Clients do often say ‘I just want someone to believe me’. It is helpful to explore using supported discovery how clients think this might help. In fact many clients have examples of people they have met over the years whom they perceived to endorse their symptomatic beliefs, and this usually was of limited benefit. More often than not what clients really seek is to feel understood, accepted and therefore connected with others, and to avoid the feelings that accompany feeling disbelieved – namely, a

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sense of disconnection, invalidation (Linehan, 1993), and being judged or labelled.

THERAPISTS BECOMING INCORPORATED INTO PARANOID BELIEFS Therapists commonly are assimilated into clients’ symptomatic beliefs, especially paranoid ones. In a fleeting way it probably occurs with most clients, but in only a few does it threaten therapy. With paranoia, spells of mistrust are probably inevitable, and can flow from schematic paranoia, or specific symptomatic beliefs, or both. With schematic paranoia it can be less of an issue – clients’ life experience has taught them to expect others to harm them, and this general perception is likely to be directed at therapists, at least for a time. Clearly, if this is very strong or generalised, it can block effective collaboration. But with most clients it is sufficient to acknowledge and accept that schema-driven mistrust of therapists is likely at times, and to encourage clients to be open about it. It can be trickier if therapists are incorporated into specific symptomatic beliefs. Therapists can be perceived as independently persecuting the client, but more usually are suspected of being in league with or working for the main protagonists. This is really a very important issue. Therapist acceptance is critical at these times. Trust is a big issue for clients, especially those with paranoia, for whom trust is loaned, not given, and subject to a variable interest rate! Accept those situations when trust is very low or absent, and try and ‘meet the person, not the paranoia’ (see Chapter 2): ‘I can imagine that it might have been difficult for you to meet me today, given that you believe I am involved in your mistreatment. I’m glad that you were able to come to the meeting today and to talk to me about how you are feeling’. For many clients, the therapeutic relationship is one of the last to be affected by increased paranoia; sustained loss of trust in therapists is thus a ‘late warning sign’ of loss of well-being. Radical collaboration works to minimise the impact of clients’ incorporating therapists within symptomatic beliefs. Therapists need to be open and consistent, doing just what they say they will. If I make a mistake, I apologise; if I am stuck, I say so; if clients ask me a personal question, I take the question at face value and answer directly, rather than exploring why they are asking me now, or what the question might mean. If the question is too personal, I would say this. If I am unsure how to reply, I would say exactly that – that I do not know how to reply in a way that is fair to us both. Radical collaboration seeks to minimise client mistrust by connecting directly with a client’s positive capacity to relate to and trust others. I try to be accepting rather than fearful of becoming incorporated into symptomatic beliefs. It can help to anticipate its occurrence (see below).

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It is disabling if therapists become fearful or anxious of becoming incorporated into symptomatic beliefs – they become self-focused, constantly monitoring and modifying their behaviour so as to try to avoid this happening. It can trigger anti-collaborative modes about competence and safety (see Chapter 2). I remember discussing with one client how literally any gesture or movement I made had a specific meaning within his paranoia. It was liberating to acknowledge that there was nothing I could do to preclude the possibility of him making sense of my behaviour in this way, short of being set in concrete. I said that all we could do was accept that this was likely to happen, and encouraged him to tell me if he was becoming mistrustful of me early on, before it jeopardised our work together. I still had occasional automatic thoughts when I realised I had made a certain movement, but let go the urge to repeatedly check out his perception, or to seek to repeatedly reassure him. Many clients find they feel more paranoid after a detailed discussion of their paranoia or disclosure of abuse or trauma. This can include heightened mistrust of a therapist as well, an understandable feeling of vulnerability and anxiety following an act of trust (i.e. sharing new and important information). It can help clients to consider likely effects of disclosure beforehand (see discussion of disclosure in Chapter 8): ‘John, what I have found with many people I’ve worked with is that when they tell me things about their beliefs, or about painful experiences, afterwards they can feel very raw. Maybe their voices or paranoia get worse for a while. Maybe they become mistrustful of me. I just want to let you know that this might happen, and say that’s okay if it does. And I hope you can discuss with me at any time if you feel mistrustful of me.’ Sometimes therapists will be incorporated into beliefs out of the blue. I recall one man, Alaisdair, who had been an inpatient for two years when he began a meeting extremely agitated, accusing me of having made him have sex with a man on the ward against his wishes. I was quite taken aback, shocked by his degree of agitation more than the content of what he was saying, and very concerned for him. On reflection there seemed to be five things that I tried to do during the session. Whenever I tried to do more than these five things, Alaisdair became more agitated. The five were: (1) not to set an agenda and generally focus more on process and relationship than structure, (2) to say how sorry I was to see him so distressed, (3) to be unfailingly honest and direct, including saying that I had not done what he believed, though I understood it was difficult for him to believe me, (4) to ask if there was anything I could do to help, and (5) communicate a wish to understand his current distress. Point 5 might be addressed as follows: ‘Alaisdair, can you help me understand how you feel? Say whatever you need to about me, however negative it sounds, that’s fine. But I would really like to try to understand. If you can’t talk to me about this today, that’s okay – if you feel you can tell me another time, I would really like to hear and understand.’

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Point 3 also merits some further comment. If I am asked by a client if I am a part of his persecution, or accused of being a part of it, I respond openly and unambiguously that I am not. This is for conceptual and practical reasons. Conceptually, if a client says he thinks his neighbour is conspiring against him, I have no way of knowing if this is so; if, however, it is I who is being accused, then I do know, and therefore can reply directly. Practically, relationship building is better served when therapists’ first response is open, direct connection, rather than a therapeutic manoeuvre such as questioning why the client has voiced this suspicion now (this can be looked at subsequently).

CONCLUSION Work with symptomatic meaning remains vital in alleviating distress associated with psychosis. It is a process of gentle exploration of proximal development. In my experience of supervision, it is when working in this domain that therapists are most likely to be prey to their anti-collaborative assumptions, trying to ‘change minds’. Working with symptomatic meaning is a social process of collaborative exploration that occurs within a relationship based on openness, collaboration and client choice. When conducted in this way it is a creative, multi-faceted and consistently relationship-building experience.

Chapter 5

RELATIONSHIP TO INTERNAL EXPERIENCE: MINDFULNESS PRACTICE1

OVERVIEW Within PBCT, mindfulness is used as the primary method for working with the relationship domain of the zone of proximal development, the central organising framework for therapy. Mindfulness practice integrates easily within a therapeutic relationship grounded in Rogerian acceptance and radical collaboration. Mindfulness is integrated within individual therapy, and also introduced in mindfulness groups (Chadwick et al., 2005). This chapter details how mindfulness meditation is introduced within PBCT, and discusses some key challenges and issues. The process of learning to respond mindfully to unpleasant voices, thoughts and images is illustrated throughout the chapter with clients’ verbatim quotations from interviews conducted by an independent clinician following completion of a mindfulness group.

DECENTRED AWARENESS AND METACOGNITIVE INSIGHT Mindfulness reduces distress and enhances well-being through two primary mechanisms. One is an experiential practice of decentred awareness (Segal et al., 2002b) and acceptance of present experience. This is not a technique, but a relational process. As Alison from one group said: ‘Step back from your thoughts and feelings, become more aware of them.’ The second mechanism is metacognitive insight. This is facilitated through education, discussion and supported discovery before and after meditation practice, as well as specific guidance during meditation. Guidance during meditation and reflective learning both highlight key facets of experience during meditation practice, such as transience of sensations. Clients gain 1

Dr Katherine Newman Taylor and Dr Nicola Abba contributed significantly to the development of the ideas in this chapter.

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metacognitive insight by articulating and thereby making explicit what is implicitly noticed about sensations (including voices, thoughts and images), reactions, and how relationship to sensations shapes emotional state. Together decentred awareness and metacognitive insight constitute the collaborative learning process whereby clients realise proximal development within the relationship domain of the ZoPD. Overemphasising the importance of meditation practice and underemphasising metacognitive insight is unhelpful. First, mindfulness can then feel daunting, as if one just has to put in endless hours of practice to reap rewards. Second, there is a danger of missing opportunities to facilitate insight, perhaps because of an assumption that it ‘will just happen’. Methods such as supported discovery substantially increase the likelihood of insight. One of the most fascinating questions in this domain of the ZoPD is how to maximise metacognitive insight derived from moments of decentred awareness – what can these moments reveal about psychosis, distress and the self? This links to a third risk, which is obscuring the basis for integration with CT. While it is true that the formal practice of mindfulness is very different from that of CT, both seek to impart similar metacognitive insights into the nature of distress/suffering and well-being. Mindfulness meditation is certainly relational, but its transformative potential is inextricably linked with meaning. Mindfulness and CT are integrated most fully when this point is seen.

Focus of Decentred Awareness When mindfulness is used within PBCT it has a specific focus, namely to bring decentred awareness to unpleasant psychotic sensations – voices, thoughts, images, tactile sensations, and so on. Clearly, clients also experience other unpleasant sensations, and these too are observed with decentred awareness. When people relate mindfully to unpleasant psychotic sensations, in those moments they liberate themselves from habitual distressing reactions to psychosis. While we remind clients that it is possible to relate mindfully to all experience, clients want to be free of the distress – the tyranny – of distressing psychosis. The fact that mindfulness has a clear focus, or aim, does not mean that the meditation itself is changed or diminished – the meditation used is the same one I learnt from meditation teachers, but it is used in service of a specific objective. Sustained motivation to pursue this aim comes from negative and positive reinforcement. Negative reinforcement is the reduction and sometimes absence of that distress which accompanies aversive reactions. As Martin said of his voices, ‘You can either let them go, or after twenty minutes you’re going to be screaming, breaking windows, throwing your shoes against the wall, banging your fists against the wall. Which one is preferable?’ Mindfulness is also positively reinforcing. As Katherine put it, ‘It gives you a physical well-being. Sometimes when you get a bad thought

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and it gets really stressful it can affect all the mechanisms in your body and the mindfulness can neutralise those which makes you feel physically better.’ As Alison put it, ‘It can be quite relaxing at times. Just being able to concentrate on your breathing and just let your mind sort (pause) and not be filled with distressing thoughts. It’s just like a relief’, or Steve, ‘Great peace, peace is the first word for it, tranquillity, silence, calm, all of those. Um, release, yeah.’

ESTABLISHING A RATIONALE FOR MINDFULNESS From the very outset I clarify that mindfulness will not get rid of voices, thoughts, images, etc. It involves practising a different way of responding to them. It is about learning to accept and live with these experiences without feeling preoccupied, ruled, dominated and overwhelmed by them. Some clients will be disappointed by this news. In part this disappointment is because it is so difficult for clients to imagine having these unpleasant sensations and not being distressed and overwhelmed (because of the A–C model of distress discussed in Chapter 4), and it is also because the sensations can be very unpleasant and painful in their own right. In PBCT mindfulness is introduced in a particular way. I first explore with people how they currently react to their distressing experiences. A range of coping strategies emerges. These are grouped either into an attempt to avoid contact with the sensation (e.g. using excessive drugs to block voices and images), or in some way getting lost in reacting to it – by resisting, fighting, neutralising, judging, struggling, worrying, searching for meaning, etc. These two coping styles are drawn at opposite ends of a diagram, and mindfulness is placed as a middle way between these two extremes – being open to and accepting of voices, thoughts, images (so no avoidance) yet letting them pass without becoming lost in reacting. Clients would then do an initial practice of around 3–5 minutes – this enables them to choose in a more informed way if they wish to practise further in a group or individual therapy. Introducing mindfulness as a new relationship with distressing experience Experiential avoidance

Lost in …

Distraction/keep busy

Fighting/struggling

Blocking out

Mindfulness

Rumination/worry

Avoidance of sensations

Neutralising

Close/constrict mind

Search for meaning

Self-harm/drugs

Judgement

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Socratic dialogue is used to explore with people the effect of existing coping – does it work and how does it feel to continually react in this way? A common advantage of avoidance is that in the short term it can bring relief. A common advantage of struggle is that it carries a valued sense of resistance. Yet neither seems to work in the longer term. Mark described feeling ‘stunned’ by his ‘gruelling’ habitual relationship with voices, adding ‘mindfulness is the only coping that is pleasurable’. It is important to be accepting of people’s continued use of existing coping behaviour, and mindfulness is offered as an additional response.

ADAPTING MINDFULNESS FOR PEOPLE WITH PSYCHOSIS A scarce literature exists on meditation and psychosis, and it contains cautions against teaching meditation to people vulnerable to (Yorston, 2001) or currently experiencing active symptoms of psychosis (Deatherage & Lethbridge, 2001). This literature refers chiefly to isolated single cases, lacks experimental rigour, and includes a wide range of forms of meditation experiences and length of exposure. The question raised by this literature is, perhaps, how mindfulness can safely and therapeutically be introduced to people with distressing psychosis. PBCT offers a particular method for doing so. The first 18 people to attend mindfulness groups I ran were interviewed by an independent clinician after the conclusion of their group. None reported harmful effects of either learning mindfulness or being in a group run along PBCT principles (see Chapter 8). The approach involves certain adaptations to traditional methods. First, within PBCT it is important to recognise that mindfulness is learned within a therapeutic setting – when we run mindfulness groups, they are conceptualised not as classes, or skills groups, but therapeutic groups. If people presently experiencing distressing psychosis are to attend to their inner experience, this requires a strong therapeutic context and relationship. Second, the length of meditation practice is limited to 10 minutes at a time, rather than the traditional 20–45 minutes, because nearly all clients find this their limit. In our groups, for instance, we would have two 10-minute meditations each session. Also, a comment lets people know when a minute or so of the 10 remains; this increases the likelihood of clients finishing the meditation with decentred awareness, which is reinforcing and motivating. A third development is that prolonged silences during meditation are avoided. During all meditations therapists give brief guidance or comments every one or two minutes. Therapists practice mindfulness with clients, and speak in the first person plural for guidance at the start and end of meditations (e.g. ‘we begin by grounding awareness in our

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bodies’), though comments in between are usually in the second person (e.g. ‘where is your awareness right now?’). This frequency of comments is a vital grounding method. Clients repeatedly have said how hearing a therapist’s voice helps them to decentre from voices, rumination, struggle, etc., and to reconnect with present experience with clearer awareness. A fourth adaptation is that practice outside sessions is not required. Audiotapes of guided meditation are supplied, also lasting 10 minutes and with frequent comments, and practice is encouraged: ‘Please attend the group each week if you are able. Beyond this we really would encourage you to practise at home, because it will give us more to work with together here, but don’t worry if you haven’t been able.’ In sessions we always ask if people have practised mindfulness, either through formal practice or spontaneously, and address any issues that come out of this (e.g. obstacles). We are accepting if people chose not to practise, which is often the case. Generally clients seem more motivated to practise with others in a group than alone. As well as formal practice with tapes, we encourage clients to use the three-minute meditation described by Segal et al. (2002b), which involves spending a minute bringing awareness to body, breathing and mind, respectively. A further development concerns how in PBCT different facets of mindfulness are stressed and in a specific sequence. Following two or three general meditations, subsequently in discussion and one or two comments during meditation practice, I focus in on those three facets of mindfulness identified in Chapter 3 (Figure 3.1) and in a particular sequence – namely (1) reacting versus letting go, (2) experiential avoidance versus turning towards the difficult, and (3) judgement versus acceptance of psychosis and self. Letting go comes before turning towards the difficult because it is empowering for clients to experience releasing themselves from distressing reactions to psychosis. Clients are then more willing to turn towards voices, etc., because they have experienced how this need not be overwhelming. Therefore for therapists this sequence feels more person centred. The following sections focus in detail on how to introduce mindfulness practice, and then on aspects of letting go, turning towards psychotic sensations, and acceptance.

PRACTISING MINDFUL AWARENESS GROUNDED IN BODY AND BREATH Initial preparation is helpful. As with all exploration of proximal development, it is important to begin where the client is. One point is to check out people’s ideas about what mindfulness is. One man thought the aim of mindfulness was to fill his mind, hence the name; another thought it was to ‘knock away’ all thoughts and create an empty, clear mind. It is vital to check again and again for this idea that mindfulness is about clearing

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the mind, getting rid of thought, voices, etc. Mindfulness is described as a way to enhance emotional, psychological and physical well-being by learning to be aware and accepting of all experience. It helps to clarify what mindfulness is not, as well as what it is – that it is not religious, or mystical or strange, but involves sitting upright and still and trying to be aware and accepting of whatever is experienced. Understanding of mindfulness is an unfolding process, and it is important to regularly ask people ‘how would you describe mindfulness?’ or ‘what does turning towards voices mean to you?’ This irons out many common misunderstandings and confusions, and supports metacognitive insight as clients articulate their personal understanding and experience in words and metaphors that are enriching for therapists, too – for example, when a person says that their mind ‘felt like a newsreel’, or that mindfulness helps prevent ‘glancing thoughts’ becoming ‘overbearing thoughts’. Clients are encouraged to let their eyes fall closed, because this reduces sensory stimulation. If clients feel unsafe doing this, they are advised to rest their vision on a fixed point in front of them, rather than roving around the room. Clients are encouraged to try to be still physically, as this is helpful both for them and others. We discuss how to deal with difficulty, saying ‘If at any time you start to feel really uncomfortable or distressed and it becomes too difficult to sit with, it can help to open your eyes. If you still feel distressed, just say “Let’s stop, Paul” [if in individual therapy], or quietly leave the room and one of us will come and talk to you outside [if in a group].’ It can help to let people know that practice might feel strange at first, a feeling that passes, or that they might become aware of surprising or unusual sensations (e.g. one woman became aware how she could feel her ribs when breathing). Again, initially clients can feel more aware of difficult sensations. People sit in a chair, in an upright position, feet flat on the floor, hands either in their lap or resting on their thighs. The first minute or two is spent settling awareness in the body. Meditation begins with awareness of sensations at points of contact, and moves up through the body, as in a body scan (Kabat-Zinn, 1990), noticing whatever sensations are present and trying to loosen any tension that is experienced. Awareness of body is a grounding method and foundation for mindfulness (Kabat-Zinn, 1990). We offer a rationale for bringing awareness first into the body: ‘We spend so much of our lives locked in our minds, that it’s important to ground awareness in our bodies.’ We draw people’s attention to the actual sensations (tingling, pressure, temperature, etc.) and how these change constantly. Having moved up through the body, people are then guided to gently bring awareness to their breathing. The intention is not to alter or control breathing in any way, but to be aware of each in-breath or each out-breath just as it is, from start to finish. We ask people to find that place in their bodies where the sensations of breathing are most accessible and comfortable. This might be at the tips of the nostrils, or the rise and fall of the chest or

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abdomen. Breathing helps anchor awareness in place and time, because a breath happens in the body and now, not in the past or future. As Richard put it, ‘If you’ve got something you can focus on, like your breathing, then it does help, it stops your mind wandering so much.’ Awareness requires a gentle concentration. If clients become tight and strain, mindfulness is lost. As Gareth said: ‘You don’t have to try too hard. The trick is not to try in a way.’ Equally, sometimes concentration needs ‘topping up’ when people have lapsed into only half experiencing what is present (autopilot: Kabat-Zinn, 1990). Guidance encourages clients to notice these differences, and find a mid-level of gentle concentration. Initially the transience of sensations, how they naturally come in and out of awareness without any effort, is more easily noticed with external sounds than thoughts or voices. Similarly, many clients initially can differentiate sensations from reactions more easily with a physical experience of discomfort or pain than with cognitions.

‘Choiceless Awareness’ It is very important to understand the place of awareness of breathing in mindfulness. In mindfulness ‘you are opening the mind up to everything. You are not choosing any particular object to concentrate on or absorb into, but watching in order to understand the way things are’ (Sumedho, 1987, p. 14). If this point is not understood, then there is a danger that clients will think that they were aware only during those times when they noticed sensations of breathing – that is, that noticing thoughts or voices or images was distraction. Mindfulness will become yet another frustrating attempt to control the mind. Breathing is not a means to resist awareness of other experiences. Clients become aware naturally of sounds, voices, thoughts, images, bodily sensations, etc., and this is in no way resisted. Once these sensations have either passed or faded into the background, awareness gently returns to rest in the body and breathing. This process occurs again and again. As Hannah put it, ‘At the end of a thought I’ll go back to the breathing.’ In this sense, this practice is called ‘choiceless awareness’, to express an aspiration to turn towards any and all sensations that enter awareness, regardless of whether they are pleasant, unpleasant or neutral. During discussion and as part of guidance during meditations we stress how mindfulness is intended neither to get rid of (e.g. a voice) nor create anything (e.g. an empty mind).

Being Kind to Oneself In PBCT, as in all mindfulness, there is a strong emphasis on being kind to oneself, and accepting that no one will be mindful all the time. In reality

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clients, like all people, are far more likely to catch themselves in the midst of a reaction to an unpleasant sensation than they are to observe a sensation come and go without reacting. As Neil put it: ‘I’m aware when I lock on to one of these thoughts or ideas or images or whatever has come into my head, when I lock on one of them and I start following it, I realise I’m doing it and then, whoa, back, refocus.’ Once clients realise that awareness had been lost, in that moment they have, in fact, regained decentred awareness, and can reconnect with experience, usually via the breath or body. As Martin put it, ‘If your mind is wandering you got to return to being aware of your breathing. Return to yourself as a starting point’, or Richard, ‘If you find it wandering you just draw a natural breath’, or Steve, ‘So you just do it again, you do it gently again, okay, just concentrate on a tingle in your hands or whatever … just get back into the routine and just forget it.’ The more clients become aware of reactions to psychosis, the more potential there is to gain insight into the impact these reactions have and to spend less time lost in them.

Noting Unpleasant Voices, Thoughts and Images While meditating, clients invariably experience some combination of unpleasant voices, thoughts (chiefly paranoid), images, tactile sensations, etc. Covert noting of sensations (e.g. note ‘hearing’) or reactions (e.g. note ‘worry’) helps establish and maintain decentred awareness. Clients are not advised to note experience in every moment (as is done in some meditation practice), but rather to note unpleasant sensations and reactions as they become aware of them. So, a guidance during meditation might be: ‘You might find that you have become lost in judging or worrying. Don’t worry, it happens to us all. Just note to yourself what you were lost in, like “worry” or “thinking”, and see if you can let that go and open awareness again to your body, breathing, to sounds.’ Concerning voices, guidance might be: ‘If you hear a voice, bring your awareness to it. Note to yourself “voice”, or “hearing”. Try not to react, but instead to observe it pass or fade. Then gently bring your awareness back to rest in the next in-breath.’ The label ‘hearing’ is used because this is the sensory quality of a voice, and the instructions on noting simply reflect the person’s experience. Some clients have found it helpful also to note the emotional tone of unpleasant sensations (see Chapter 3). One man, for example, experienced numerous paranoid sensations, which he was able to learn to respond to mindfully much of the time, but he also experienced sexist and racist intrusive thoughts which he found extremely difficult to accept without judgement, struggle and rumination. For these thoughts it helped him considerably to note ‘unpleasant thought’ – making sure that ‘unpleasant’ was a description of the emotional tone of the sensation, not a judgement.

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PRACTISING LETTING GO OF REACTIONS It is fundamental to mindfulness to understand what it is that people let go of. It is impossible to hold on to sensations. Each sensation is transient. What clients learn to let go are their habitual reactions to unpleasant (psychotic) sensations – the struggling, fighting, swearing, avoiding, judging, worrying and ruminating. Letting go occurs when there is awareness of a reaction. A reaction might have been happening for minutes, yet letting go can happen only once there is decentred awareness. Also, letting go differs from experiential avoidance, which is a rapid pulling away (aversion) at the moment of contact. Noting a reaction (‘worry’) works against any rapid pulling away, and sharpens a sense of choosing to let go of something that has been recognised. As Steve put it, ‘To me my normal state of affairs is I’m moving all the time, I’m running away or I’m scared; this mindfulness thing, this tingly little microcosm that you can get is for a few minutes, it’s just a few minutes release and peace from that and it’s the first time where I stop moving.’ As Jane put it, ‘Um, it’s a way of trying to, not get the thoughts to go away, but to stop worrying about them and the anxiety about them.’ As Richard put it, ‘You get a thought coming in and it’s a case of down tools’, or Alison, ‘It’s like you have to unlearn your responses to these thoughts and feelings. It’s like a release for these thoughts and feelings that are (pause), not being tied to fighting with them and struggling with them.’ As Peter put it, ‘I remember to try and stay calm when I get a bit of turmoil in my mind.’ Martin described letting go of rumination and worry as ‘letting go of voices and the meaning of what they’re saying, not worrying about what they’re saying.’ As clients gain metacognitive insight into the physical and emotional impact of their habitual reactions to psychosis, they become disenchanted with them and a rationale and motivation for letting go of reactions builds. As Alison put it, ‘Just sort of get fed up with the same old pattern, you know, I’ve been here before, struggling, trying to work them out, fighting … Let things come and go and not let them sort of linger and not work on them. If they come you just let them go and they’re not there and you’re not fighting with them and you’re not struggling with them.’ Letting go is made difficult by three types of metacognitive belief, defined in Chapter 1 as metacognitions that support distress. First is a belief that letting go of reaction will create a feeling of loss. As Damien expressed it: ‘You don’t mean letting go of everything, do you. If you let them go all the time, what have you got left? Nothing.’ Damien heard the voice of his father, who had abused him but also showed him love. He was tormented by his struggle with the voice, but feared losing it. For Damien it was vital to experience how letting go of reactions actually meant that sensations such as voices and feelings were experienced more clearly and fully. People can fear losing even malevolent voices because the relationships with

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them are interpersonal, complex and emotionally laden (Benjamin, 1989). It is important to remind clients that we cannot get rid of sensations. Indeed, decentred awareness arguably brings voices, thoughts, images, etc., into clearer focus. A second obstacle is fear that letting go of habitual reactions will lead to feeling overwhelmed. This fear is fuelled by metacognitive beliefs that struggle against unpleasant psychotic sensations reduces their impact, and keeps a person safe from harm. It can be very helpful to set meditation practice up as a direct behavioural experiment of this – perhaps saying ‘would you be willing to test this out, to not fight and swear at the voices just for these few minutes of practice, and see if it leaves you feeling more overwhelmed and distressed than fighting them incessantly?’ A third metacognitive belief that supports distress and struggle is the belief ‘unless I think about what the voices or thoughts mean I will miss important discoveries and realisations’. As Peter said of his paranoid rumination: ‘Sometimes you just want to work it out, so you won’t let go until you have.’ Of course there are times when discursive thinking is necessary, to plan and problem solve, for example. Yet so much of the rumination around voices and paranoia is repetitive, circular, distressing and draining. Clients do not suddenly stop reacting; rather, they become more aware of these habits, of their impact, and the beliefs that support them. And in those moments of not reacting, or letting go of reactions, they experience how it is possible to relate to psychosis in a fundamentally different way, one that is empowering and liberating.

PRACTISING TURNING TOWARDS UNPLEASANT PSYCHOTIC SENSATIONS Turning towards unpleasant sensations (Kabat-Zinn, 1990) is a deliberate act and different from psychotic experience intruding into awareness in spite of the person’s best efforts to keep it out. It is about contact with psychosis rather than immersion in it. As Martin put it, ‘Listen very carefully to the voices and each time they become distressing don’t get distressed ’cos otherwise you’re going to be spending the rest of your life getting distressed’, or as Steve put it, ‘If you get one of these thoughts into your head you don’t engage, you neither engage, well no, you engage with it in a different way. Instead of going huh! and pushing it away or going huh! huh! and engaging with it, you just (pause) the idea is you accept it.’ Turning towards difficult and painful sensations does not have to occur at the moment a sensation begins, but rather the point at which a person becomes aware of it (trying to catch the moment a thought or voice arises can be frustrating and create tension). Turning towards difficult experiences has a quality of curiosity, of wanting to see clearly what exactly is being experienced. If a person has

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a painful knee, turning towards it is about exploring what exactly this ‘pain’ is – and finding perhaps a changing mix of tension, pressure and temperature. With voices that are persistent, observing the form of the sensations (tone of voice, volume, etc.) supports decentred awareness, as does noting, and lessens the likelihood of being lost in content and struggle. It is once a person has decentred and let go of trying to get rid of unpleasant sensations that those sensations can be seen most clearly for what they are. As Michael said of his paranoid thoughts and images, ‘Your mind goes round and round in circles, not really getting anywhere. You are giving the thought a lot of power by the time you spend struggling with it. Letting go helps, you avoid getting into some ritual that goes on longer than the actual thought or image itself.’ Bringing awareness to voices, thoughts, images, etc., is a pragmatic stance that comes from the metacognitive insight that none of us can control what comes into mind. This can be illustrated by methods such as therapists clapping their hands, and asking if anyone chose to hear the sound, or if anyone chose not to. The question simply does not make sense. It is not possible to ‘get rid of’ unpleasant sensations, so the challenge is to relate to them differently. What makes uncontrollability of psychotic sensations difficult to accept is not only the inherent painfulness, but also a pervasive rule or assumption along the lines ‘I can never find happiness until I am rid of these voices, thoughts, images’. Unwittingly psychiatry often reinforces this view. A positive alternative rule, which supports wellbeing, is ‘I can find happiness and peace if I can be aware and accepting of these unpleasant experiences as they are’. As John said, ‘It’s not so much control the voices, as be more peaceful with them.’ Turning towards the difficult is supported by growing metacognitive insight that sensations are always changing – something that is stressed in meditation and reflective learning. After a meditation I might ask clients to estimate how many different sensations came into awareness in the 10 minutes and then perhaps practise for a further minute focusing on transience. Or I might ask people how long they think they could hold their attention on voices or thoughts without noticing something else – people quickly come to see that the answer is a very short time. Likening thoughts and sensations to bubbles, a traditional metaphor, can make this point. Measures like these help to undermine the power (omnipotence) that voices and even thoughts/images can have, by placing them within a flow of changing sensations, and to sow seeds of acceptance of psychosis and self (see below). As Peter put it, ‘The ideas are still there, still get these niggling little thoughts and stuff but it’s just sort of like, taking on board without overreacting to them, just listen to what you know the idea is and then you know, sort of kind of accept it rather than be like unrealistic about it, thinking that’s completely wrong, it shouldn’t happen.’ As Gareth put it, ‘Let the voices happen and you’ll find out they meant nothing anyway. How

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can I put it – if you’ve got voices controlling you, try and just let it and then you’ll find out that it didn’t control you after all. It’s just a voice.’

PRACTISING ACCEPTANCE OF PSYCHOSIS AND SELF A primary aim in PBCT is to promote Rogerian acceptance of all experience and for this to be a basis for self-acceptance (Chapter 1). Self-acceptance is threatened by habitual negative judgement of self, or of sensations (voices, thoughts and images). Judgement of sensations is a profound threat to self-acceptance because it leads so easily to self-judgement, through metacognitive beliefs such as ‘bad people have bad thoughts’. As Sally put it, ‘If I’m judging the thoughts I have I can judge myself as good or bad. So if I’m not judging, it makes me feel better about myself.’ Mindfulness increases awareness of reactive judgements of sensations and self. The aim is not to strain to stop judgmental sensations or reactions from occurring, which would be a version of the impossible task of ‘getting rid of’ unpleasant cognitions. Rather it is to become more aware of judgmental thinking about sensations or the self, and its physical and emotional impact. This generates motivation to practise letting go of the tendency to reactive judgements. As Neil put it, ‘You don’t have to worry about what’s right and what’s wrong in your head, you know, it’s that not judging what’s going through your head, it’s just accepting it as what it is, not worried about vindictive voices, or whatever, it’s just accepting it, that’s the way it is. No right, no wrong … Whereas before, this kind of stuff was happening I was fighting against it, thinking ‘‘no this is wrong, this is wrong’’, fighting against these images.’ Judging will inevitably still occur, and clients can practise watching judgements come and go, and accepting them as an aspect of self, but not the self: as Steve said: ‘Realising you have an internal critic that isn’t exactly you, it’s learnt behaviour.’ This is a radical shift, and requires using supported discovery to uncover assumptions and metacognitive beliefs that support judgement. Mike illustrates this process well. He had considerable difficulty in accepting certain thoughts and images, which he found intensely distressing. He would react forcefully: ‘When I react, I react strongly. It’s a bad thought or feeling. It needs to be corrected, or put right. The struggle is everything.’ He would try to experientially avoid them, shouting aloud ‘Stop it, stop it, you don’t really mean that’. The thoughts provoked strong judgement: ‘It’s wrong. I don’t want these thoughts. I don’t want to be the person having these thoughts. Why am I thinking these things? I didn’t use to. I’m a bad person, sick in the mind.’ These judgements were supported by metacognitive beliefs that defined the self in terms of uncontrollable sensations, rather than his reactions to them: ‘I should not have these experiences, only a sick person would have thoughts like these.’ In a group session Sally encouraged Mike to decentre from these thoughts

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by focusing on his ethical objection to the content of his thoughts, and see this as self-expressive: ‘It’s not you. If it was us we wouldn’t feel as bad about it. If it was us we wouldn’t feel bad about having them.’ Acceptance of unpleasant and unwanted sensations does not mean agreement, or endorsement, or passive resignation. It means accepting that in this moment, this is my experience; it requires decentred awareness. For clients acceptance remains an ongoing challenge. As Laura put it, ‘When I find it hard to accept them is when I wake in the morning and they are there, straight away. A person has a right to some peace, some quiet in this world.’ To accept voices first thing in the morning is not to believe something about voices; it is to relate to them mindfully. Acceptance is neither an outcome nor a belief, but a process of meeting difficult experience mindfully over and over again. It is ironic how in everyday speech we often say ‘just accept what is happening’, as if it were a small thing, because it is one of the most profound things we can bring to difficult experience. It is crucial that what is accepted is the psychotic sensations stripped of the person’s reaction. As Steve put it, ‘You know this big thing that comes in with lots of bluster, if you do that [respond mindfully] it will deflate down, and deflate to this tiny little thing you can just discard. You know it’s just a load of hot air and bluster.’ Decentred awareness of voices fundamentally challenges their omnipotence. In each moment that a voice, thought or image is deflated, and experienced with decentred awareness, psychosis is seen less and less as the basis for self-definition. Accepting psychosis supports self-acceptance, because psychosis ceases to define the self. As Neil put it, ‘I would judge me on my thoughts, my voices, my images, I would judge myself on those and they were usually pretty negative (pause) and listening to someone else’s experience, who I regard as so-called normal, or whatever, and that their experience was the same, that helped me accept a big chunk about myself. I’ve thought that basically that I’m not wrong, that I’m quite acceptable.’ This quotation shows how mindfulness practice supports self-acceptance by letting go of self-judgement – that is, reducing or foreshortening activation of NSS. Mindfulness practice also helps those clients who have lost a sense of self altogether, rather than struggling with negative self-schematic judgements. Gary described this loss as follows: ‘I’ve lost touch with myself, I’m like a zombie, a vacuum.’ The process of mindful awareness gradually reconnects clients with their experience, which can be developed into a metacognitive symbolic self.

USING CT SKILLS TO FACILITATE METACOGNITIVE INSIGHT In Chapter 1 I argued that decentred awareness does not automatically yield metacognitive insight. One of the most stimulating aspects of

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integrating CT and mindfulness is precisely how to facilitate metacognitive insight. Throughout this chapter there have been examples of using CT methods to draw metacognitive insights out of mindfulness practice. What CT brings is an established process for supporting proximal development. This means both bringing into awareness those implicit metacognitive beliefs that underlie distressing habitual reactions, and articulating new metacognitive insights that support well-being. The following exchange from the start of a mindfulness group meeting illustrates this in a fashion that should be very familiar to cognitive therapists. Anna: I had these feelings for a married man, who is unobtainable. The feelings were nice, but I can’t have him so I didn’t want these feelings. I tried to use mindfulness but it didn’t help. So in the end I just had these feelings for hours, not wanting them. Therapist: So, you had feelings that were pleasant but didn’t want them because he is unattainable, is that right? Mindfulness didn’t help, is that right? Anna: I couldn’t stop the feelings, it just got worse. Therapist: You wanted to get rid of the feelings, to use mindfulness to stop them? (To the group) Is mindfulness the same as getting rid of thoughts? Janice: No, getting rid of feelings, you’ve pushed it away, got nothing left. With mindfulness you’ve got something left. Therapist: That’s right. Mindfulness is not about pushing experiences away. We allow them to happen and try to be accepting of them. Anna, it sounds like you didn’t accept the feelings, is that right? Anna: Yes, that’s right, I didn’t accept them. He’s a married man with children. He’s unobtainable. Therapist: Anna, it sounds like what caused the distress was not the feelings – they were nice – but not accepting them. Is that right? (Anna agrees) I wonder, what experiences do we find it hard to accept? John: Fear. Because of not being able to handle your emotions when in that fear. If a thought makes an unreasonable demand, if an anxiety does. Therapist: Can you say a bit more about this, I haven’t quite understood you? John: To do with breaking rules of living, of society, what’s right. A fear that I might end up breaking a rule. Therapist: That sounds really important, John. Has anyone else had that kind of experience, of not accepting a thought or voice or image because it seems to break a rule? Peter: When the voices tell me to be violent. John: To fight people, do they tell you to fight people? Peter: No, not to fight people. Just to harm them, or harm myself. Therapist: And these voices are hard to accept. Peter: Yes, you want to get the violence out of your system – not to be violent, but to not have the violent voices and thoughts.

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John: You shouldn’t be having these experiences. Therapist: Who says we shouldn’t have thoughts like this? John: It’s what you are taught by authority. By our parents. Peter: The voices tell me it’s bad to have them, that I’m bad. Anna: It’s bad to hurt other people, isn’t it? Therapist: Yes, that’s a really good point. Harming other people is bad, something to avoid. But is that the same as having a thought or voice about harming someone else? Anna (after a long pause): There’s no harm in having these thoughts, just don’t act on them. Socratic dialogue is a powerful means of facilitating clients to express metacognitive insights in their unique words, images and metaphors. These can be about the emotional, physical or psychological differences between being fully aware of present experience or being lost in distressing reactions; between avoiding or turning towards difficult sensations; between judging or accepting experience; between being lost in struggle or decentring from it. From a solid experiential foundation, clients are able to articulate metacognitive insights that support a mindful relationship with psychosis. There is a sense in which mindfulness practice within PBCT is an ongoing process of experiential behavioural experimentation, in which metacognitive beliefs are weighed against emerging metacognitive insights. Clients are encouraged to contemplate: What happens if I do not try to get rid of the voices, but turn towards them – would I be overwhelmed, as I fear, or might I be able even once to hold a more equal position with these voices that seem so powerful? How does it feel to let go of struggling – will it feel like a defeat, as my beliefs predict, or might it feel like a relief as others in the group suggest? This is the essence of integrating mindfulness practice within PBCT, and realising its potential for easing distress and promoting metacognitive insight and well-being.

SOME KEY ISSUES AND CHALLENGES This section describes some challenges and issues so far encountered when introducing mindfulness to people with distressing psychosis.

Not Being Drawn into Meaning For cognitive therapists, an immediate challenge is to be able to separate and move between exploration of relationship with experience, and exploration of meaning – to be able to work in one domain of the ZoPD, and to bookmark interesting points that belong in other domains. In one

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of our groups, for example, a woman reported feeling considerable distress while experiencing images of her mother (who was alive but old and frail) lying dead. Were the aim to explore how meaning contributed to distress, a standard ABC assessment would be followed. But if the aim is to explore how relationship with this sensation contributed to distress, then the key questions are whether she was able to turn towards the images, with full awareness, to accept them without judgement, and to let them pass without rumination.

Distressing Reactions are Fossilised Behaviour Reactions such as judging sensations and self, or rumination, are complex psychological reactions that have become ‘fossilised’ (Vygotsky, 1978). The very capacity to judge ourselves or our experience, for example, is the result of a complex social and developmental process. The origins of such behaviours become lost with time, to the point where reacting to unpleasant voices or thoughts with judgement or rumination can seem automatic, as if a person has not control of it. An important aspect of mindfulness is to begin to bring back into awareness the degree to which avoidance, judgement, rumination or worry are not automatic reactions, but responses that do not always have to be made. Once clients decentre from distressing reactions they become aware of the effort involved in them, and how they can choose to invest yet more energy or let go of struggling. It takes only a few instances of decentred awareness plus metacognitive insight to know experientially how in any given moment it is possible to free oneself.

Judging Behaviour PBCT emphasises letting go of judging sensations and self. This means accepting all internal experience, and unconditional self-acceptance. Therapists need to avoid any judgement of clients (see Chapter 2) – that is, of clients as people, or of their behaviour, sensations, thoughts, ruminations, etc. Yet many clients find it helpful to judge their behaviour. This is fine so long as it does not trigger NSS – self-judgement so often lurks in the shadow of a judgement of behaviour. Ellis’s REBT has long recommended rating behaviour, not people (1962). And what if a client has a flashback to an experience of being abused? Is a client being encouraged to accept the other person’s abusive behaviour? Absolutely not: the encouragement would be to meet the flashback with acceptance, and decentred awareness, and to observe it pass without reacting.

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‘Good’ and ‘Bad’ Mindfulness Practice One of the most pervasive tendencies people have when they begin meditating is to judge their practice – for example, as better, or worse, than the last one. It is important to normalise this tendency but also to encourage people to be aware of and note the judging. Much judgement of practice is driven by aversion to psychosis, and the implicit rule ‘In order to be happy and peaceful, I must be free of unpleasant psychosis’. Therefore a practice is judged as better if there are fewer voices or worse if there are more unpleasant images. People so much want their distress to end that they often say mindfulness ‘did not work’ because they still heard voices or that it worked only for a time because ‘the worries came back again’. What they are implicitly asking is, ‘When is mindfulness going to stop these things coming into my mind?’ Mindfulness is about easing distress by not reacting, rather than blocking sensations. We emphasise how, with time, clients will become more aware of their tendencies to react, and more able to make reacting or not reacting a choice. It is also very common for clients to judge themselves as poor meditators, asking themselves: ‘Why can’t I do this?’ It is important to instil hope when people begin mindfulness practice. I might say at the start of a first group meeting: ‘I can imagine you could tell yourselves that you won’t be able to meditate, maybe because your concentration is not good enough, or your voices are too powerful, or your mind is too jumbled. Everyone here can become more aware, everyone. So let’s practise this together and support each other in doing that.’

There is Nothing to Achieve or Create Another way to instil hope is to explore collaboratively how mindfulness is not about trying to create or achieve anything. There is nothing to fail or succeed at. So many clients think mindfulness must be about getting rid of difficult sensations and creating an empty mind, or a state of either joy or relaxation. This belief is remarkably deep seated and strong, no doubt because clients want relief from distress and see this as the way to achieve it. Yet the belief means clients can strain to achieve it, and feel despondent if it does not happen. I disclose how I get lost in just those cycles that they struggle with, of experiential avoidance, judgement and rumination. In guidance I regularly say things like: ‘For these few minutes there is no need to try to get rid of anything. There’s no need to fight or struggle, no need to work anything out. No need to try to empty your mind. No need to plan anything. See if you can give yourselves these few minutes practising being aware of whatever you experience, just letting it happen,

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accepting it.’ Mindfulness is being aware in a decentred way, of what it does not matter.

Constant Voices In an early mindfulness group, two of the five participants were experiencing voices that spoke with variable loudness continuously throughout the day (‘constant voices’). This is a challenging experience not only for clients – therapists can lose sight of the value of mindfulness if voices appear not to be transient. It is helpful to keep in mind that other conditions can have fairly constant unpleasant sensations (e.g. chronic physical pain), and that each voice comment is actually a new sensation – it is only at the conceptual level ‘my voices’ that an appearance of constancy exists. The useful question is this: where is the attention? At times when the attention is drawn to the voices, let it rest there with as much openness and acceptance as possible, perhaps noting the changing nature of the sensation (e.g. content, volume). Pulling awareness away from the voices will create tension and stress. When the voices fade more to the background, the attention will naturally move back to the breath, body and other sensations without struggle. Let awareness rest in these other experiences and if voices persist in the background, let them be. This process will occur repeatedly and requires perseverance, and it can help to validate how difficult it can be to stick with. And fundamentally, keep in mind that the distress – what the person wants to be rid of – comes from the aversive reactions.

Voices and the Attention Drain Even for people whose distressing voices are not constant, the impact of voices will far outweigh the amount of time they speak. First, lengthy rumination and search for meaning occurs – people find themselves asking: ‘Why have they said that? What did they mean?’ Also there is a powerful attention drain whereby clients are very often anxiously waiting for voices, even when they are silent. It can be difficult for clients to give their attention 100% to anything else (including therapy). Many clients dislike the way voices suddenly appear, or intrude – it can be startling (Romme & Escher, 1994), provoking an immediate and strong emotional reaction, almost like a physical assault. Being vigilant can lessen the shock. Thus mindfulness is beneficial not only in helping clients to take a decentred perspective on voices as they occur, but also in providing a safe opportunity for clients to practise giving attention fully to other experiences when voices are silent.

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Mindfulness in the Eye of a Mental Storm For most if not all clients it is very difficult to remain mindful of unpleasant psychotic sensations. What are people to do at times when voices, paranoia and images are very strong? First, it is helpful to keep in mind that this will pass. Second, it is important to validate any decentred awareness of sensations or reactions at these times. People often add to their misery by telling themselves that they were not able to observe the breath because of the psychosis. I ask questions like: were they able to notice the voices, how unpleasant and loud were the voices, or how hard was it to concentrate and be attentive This is to be mindful – to be with what is present, not block out prominent sensations and cling to the breath. Third, it can help to connect more strongly with the body – perhaps even by resting a palm flat against the belly, and feeling the movement. Fourth, while routinely people close their eyes when meditating, if this becomes too difficult, it can help to half open the eyes and let them rest on a fixed point in front of the person (i.e. not roaming around). If a mental storm occurs at home, some people find that they sometimes need additional support over and above a meditation tape. One man, for example, found that at such times he sometimes needed to listen to his mindfulness tape with classical music playing in the background. Otherwise his voices were so strong that he would lose himself in them altogether. I encouraged him to be mindful of whatever was foremost in his mind in any one moment – be it music, breathing, voices or anything else.

Relaxation versus Mindfulness In a moment of decentring from distressing reactions there is a palpable relaxing of tension emotionally, psychologically and physically. This relaxing (verb) is not the same as being in a state of relaxation. While there are times when clients feel a state of relaxation when they practise mindfulness, this is neither necessary nor the aim of practice. A common misunderstanding clients make is to think that mindfulness has only occurred (or worked) when they feel relaxed and have a clear and calm mind. Mindfulness is ‘choiceless attention’ – that is, it is to be aware of and accepting of whatever is present in that moment. If you are feeling cold and miserable, it might be relaxing to imagine a beach on a warm day, but this is avoidance of what is present. This distinction needs to be addressed regularly. Also, there is a risk that people will view practice as ‘time out’, an opportunity just to let the mind drift. Gentle concentration is needed to maintain decentred awareness – as Anna observed, ‘mindfulness is harder work than relaxation, there are times when I’m too relaxed to be mindful’.

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SUMMARY This chapter explores some of the key practical and conceptual issues in using mindfulness to explore proximal development in the relationship domain of a client’s ZoPD. Experientially, psychosis is a tendency to experience certain sensations, many of which are unpleasant. A key theme in the chapter is to maximise metacognitive insight, self-acceptance and emotional well-being from key moments of decentred awareness of these unpleasant psychotic sensations.

Chapter 6

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OVERVIEW Within the Zone of Proximal Development (ZoPD) domain schemata, proximal development occurs primarily through work with negative self schemata (NSS) and positive self schemata (PSS) – and less commonly with negative other schemata (NOS). NSS are brought into balance, accepted and seen metacognitively as emotionally charged experiences of self, rather than ‘the self’. The main methods used to ease distress and disturbed behaviour associated with NSS are mindfulness, shame-attacking exercises, experiential role-plays and two-chair methods. The chapter focuses mainly on the last two, as mindfulness is dealt with in Chapter 5 and shame attacking is a conventional CBT method. With PSS the aim is to draw out, maintain and generalise emotionally vivid positive schematic experience. In this chapter the intention is to focus on a PBCT approach to working with schemata psychosis – interested readers wanting to explore the considerable literature on schema-focused approaches might begin with key texts by Young (1994) and Safran and Segal (1996).

CONCEPTUAL AIMS WHEN WORKING WITH NSS Formulation of schemata (negative or positive) describes and organises in a useful way a complex gestalt of present experience – symptomatic beliefs, feelings, behavioural urge and action, and body state and image; underlying assumptions or rules; and global/stable appraisals of self, others and future. A schema is thus not only a belief. It is, perhaps, not even usefully thought of as a cognitive structure. It is more usefully described as a cognitive–affective experience of self that is laden with explicit and implicit meaning, and it is the affect and meaning that are at the forefront of the client’s mind. Throughout this book, when I refer to schemata I always imply this cognitive–affective experience of self, even if at times I use shorthand and mention only the belief component (e.g. I am totally and inescapably bad). A crucial task when formulating schemata is to make explicit the implicit meaning. In PBCT, particular emphasis is placed on the global and

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stable phenomenological quality of schemata – qualities which usually are implicit. When an NSS is actuated, it is as if the experienced self is ‘one dimensional’ – globally (i.e. the whole self) and inescapably (i.e. stable, cannot change) bad, flawed, etc. It is like a drop of ink in a glass of water. This experience of self is ‘hot’ emotionally and has a significant impact on the person’s symbolic self (see Chapter 7). There is a subjective ‘truth’ to such experiences, a kind of self-evident emotional validity that appears to brook no argument and gives schemata force and durability. In PBCT there are four linked conceptual aims when working with NSS. The first is to become experientially aware of the phenomenology of negative schematic experience. This means recognising how it is experienced emotionally, psychologically and physically. The second aim is for client and therapist to accept the negative schematic experience as a fact of experience – that is, to accept that there have been and will continue to be times when the person’s emotional experience of self is powerfully negative, and has a felt sense of being the true self. This process of clear awareness, understanding and acceptance of the NSS is a powerful stance. The third aim is to recognise negative schematic experience for what it is, not what it appears to be – that is, to gain metacognitive insight that it is an experience of self, not the self, thereby directly challenging the global, stable qualities. The fourth aim is to reduce fear of negative schematic experience. Collectively these aims bring about a new relationship with NSS.

EXPERIENTIAL METHODS OF CHANGE Schematic experiences of self are characterised by affect and physiological arousal, and they drain energy. A conventional verbal challenge can feel unproductive, perhaps engaging the propositional but not implicational meaning base (Teasdale & Barnard, 1993) or inferential rather than evaluative processing (Ellis, 1962). Indeed, in a very real sense there is nothing to challenge or dispute with an NSS. It is undeniable that when an NSS is actuated, in that moment that is the person’s experience, so it has experiential validity. In PBCT a range of experiential approaches are used for working with schemata. Experiential methods are effective in accessing emotion and facilitating emotional change (Greenberg et al., 1993). We use four principal experiential methods – namely, mindfulness, shame attacking, twochair methods and experiential role-plays. In practice all these methods address all four conceptual aims to some degree, and are used in a radically collaborative way. For example, clear understanding and acceptance are achieved not only through mindfulness (see Chapter 5), but also twochair methods (see below) where the NSS is placed in one chair, expressed in a clear, focused way, and then viewed from a second chair, creating a clear metacognitive perspective on it.

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In this section the first two methods are described in brief; mindfulness has been discussed in Chapter 5, and shame attacking is a conventional CBT method. Role-plays and two-chair methods are discussed at length in subsequent sections.

MINDFULNESS AND SCHEMATA Mindful understanding and acceptance underpins the entire PBCT approach to schemata. More specifically, in Chapter 3, four qualities of distressing reactions to experience were stressed – experiential avoidance, rumination, judgement and absence of clear (decentred) awareness of present experience. These are relational properties of negative schematic experience. That is, the right-hand side of Figure 3.1 is depicting, among other experiences, negative schematic experience from a relational perspective. Negative schematic experience is defined relationally by attempts at experiential avoidance, by intense judgement of self or others, and by rumination on schematic meaning and memories. The self has become reified, solidified, fixed – again, the global, stable felt sense. Mindfulness alleviates schematic distress through deactivation and compensation (Barber & DeRubeis, 1989). That is, if clients maintain a decentred awareness of unpleasant psychotic sensations, schemata will be activated less frequently. Also, when schemata are activated, and clients are lost in them, mindfulness is a means of decentring from schematic experience and gaining metacognitive insight. Negative schematic experience is viewed less and less like experiencing the ‘true self’ and more like being lost in a tight vortex of bodily sensation, emotions and cognitions that limit the self.

SHAME ATTACKING AND SCHEMATA Where behavioural experiments are tests of symptomatic meaning (see Chapter 4), shame-attacking exercises (from REBT: Ellis, 1962; Trower et al., 1988) are concerned with schematic meaning, and in particular a person’s ability to tolerate and accept negative schematic experience. The traditional example is of a man (I believe Ellis himself) who fears rejection by women. He sits on a park bench and asks the first 100 women who pass by for a date. It is not a test of symptomatic meaning (e.g. no will ever go out with me) – it is, in fact, intended to ‘fail’ in this sense. It is an opportunity through repeated voluntary exposure to feel and accept how schematic distress can be tolerated, need not define the self, and will habituate. In PBCT shame attacking is carried out in exactly the same radically collaborative way as behavioural experiments when working

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with symptomatic meaning. It is helpful with shame attacking to have a positive alternative rule, just as behavioural tests are enhanced by having an alternative to the symptomatic meaning. A negative underlying assumption might be ‘If I am rejected it means I am worthless’ and a positive alternative rule might be ‘Rejection is painful but cannot reduce my value as a human being’.

EXPERIENTIAL ROLE-PLAYS: USING SOCRATIC DIALOGUE WITH VOICES One of the commonest ways for schemata to be actuated in psychosis is by derogatory voices, which repeatedly denigrate the person. These judgements have a quality of being other-self schemata, because relationships with voices are interpersonal (Benjamin, 1989). Thus, with people who hear voices it is possible to use standard Socratic dialogue in an experiential and powerful way because the critical other (i.e. voice) is present, thus avoiding intellectual discussion. For certain clients this interpersonal quality even extends to being able to converse with their voices in sessions in surprising ways – for example, by asking voices questions to clarify points throughout a role-play and receiving answers. More usually, though, voices do not converse directly in this way and clients express what they perceive the voices to mean. Role-plays using Socratic dialogue with voices have two aims. Clients are experientially establishing a different interpersonal relationship with the critical voices, and in the process are also challenging the global, stable felt sense of their NSS. Role-plays are most likely to facilitate proximal development if therapists remain focused. Often in role-plays, clients will make statements that relate to other domains of the ZoPD, yet it is better to let these pass than hop around and lose focus. Video or audio taping role-plays and then reviewing them helps clients to process what happened and promotes and consolidates proximal development. This also means that therapists can use the recording later to work in other domains of proximal development. A typical process is described below. (1) It is important to explain what would be done and why, and ask if the client wants to do it. I would say that it might be difficult at times, and like any new skill will probably need to be done a few times to get the hang of it. (2) Clarify what voices mean by their judgements and criticisms, particularly exploring the dimensions of globality and stability. Useful questions and statements are: What does the voice mean when it says you are useless? Does it ever say well done, that you did something really

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(3)

(4)

(5)

(6)

(7)

well, or are you still waiting to hear that one? So it means you are always and will always be useless at everything you do. Is that right? You’d never do anything right, is that it? That’s actually quite a claim; do you know anyone else who is like this, who always gets everything wrong all the time? Have you ever known or heard of someone like this? (Steps 2 onwards can be repeated and practised.) Critical voices can be likened to film critics who are utterly scathing of every film they ever see – a stance that is uninformative, uninteresting and reveals more about the critics than any film. Begin with the therapist role playing the client, and the client role playing the voice. Clients begin being derogatory towards the therapist. Therapists model a calm, decentred Socratic stance – a powerful alternative to clients’ habitual submission or battle. The point is not to get drawn into symptomatic meaning by challenging a specific inference (‘you messed up your homework yesterday’). Inferential statements can be acknowledged if they apply, or let them pass. It is schematic global and stable judgement that is the focus: ‘You keep calling me crap, stupid. What do you mean? What’s the evidence that I always get everything wrong? I know I do get some things wrong, everybody does, but what’s the evidence that I always get everything wrong? Why can’t you see the things I do well?’. Next it can help for clients to practise a role-play ‘defending’ either a close friend or someone they admire. The therapist would role-play the critical voice, directing the comments at the friend, not the client. The client disputes the voices’ criticisms. This allows the client to practise Socratically questioning voices in a less personal role-play. Therapists now role-play the voices, and clients are themselves, practising Socratic dialogue. To begin with therapists choose milder criticisms from the voices’ repertoire, and tread softly (i.e. no broadside of abuse), helping clients to develop confidence and skills. This can be practised several times, gradually becoming a little more forceful. There is no need to role-play voices at their worst, because for most clients Socratic dialogue with voices, like most coping strategies, will not be effective at such times. Therapist and client isolate two or three strong Socratic questions that worked best for the client and felt most useful. These can then be written on cue cards, recorded in voice boxes on mobile telephones – whatever is most accessible for the person. The client practises the new skills in sessions with the voices’ and therapists’ coach where needed. The client tells the therapist how, if at all, the voices respond to Socratic questions. A decision is taken jointly as to whether the client feels ready to generalise the skills and dialogue with voices outside sessions, and if so how this might be done safely, and what might be learned from it.

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TWO-CHAIR METHODS FOR BRINGING NSS INTO BALANCE Two-chair methods are widely used in PBCT. Chapter 7 presents a two-chair method for drawing out a PSS, and working to promote selfacceptance. While conceptually drawing out a PSS belongs in the schemata domain of the ZoPD, it is placed in Chapter 7 to allow the reader to see the complete two-chair enactment in one flow, with a therapy transcript running alongside. In this section, I describe some uses of two-chair methods for working to bring negative schematic meaning into balance. Negative schematic meaning linked to abuse and trauma, or to derogatory voices, can be so dominant that experience, attitudes and feelings that do not fit with it are lost to awareness. The two methods described in this section are examples of bringing negative schematic meaning into balance by taking a metacognitive perspective on it and bringing into awareness other contradictory meaning and feelings. The use of two-chair methods within PBCT has developed from Greenberg et al.’s (1993) important and pioneering work on the use of two chairs in experiential therapy. Both main two-chair enactments described by Greenberg et al. (1993) are useful in their own right, but the value of the work goes well beyond this. Greenberg et al. chart key principles that underpin effective two-chair working – the two-chair method itself is a flexible process that can be tailored and adapted to suit different clients and conceptual goals. Integration of the two-chair method within PBCT is possible because of shared practical emphases on a collaborative relationship, and the centrality of Rogers’ (1961) concept of acceptance, whereby therapists strive to show a consistent, genuine, uncritical interest and tolerance of all aspects of the client. Moreover, both approaches place an emphasis on learning through guided (emotional) experience. The twochair process is fundamentally Socratic – that is, supported discovery is used to draw out clients’ own experience. Whenever possible therapists form summaries, questions and reflections using the clients’ own words, metaphors and imagery. Integration is also supported by shared theoretical emphases. First, there is the central importance both approaches place on the subjective perception of self, and how this links to emotional distress and confl ict. The word scheme in Greenberg et al.’s approach is very close to the cognitive concept of a schema – both are deep and fundamental meaning structures (with cognitive, emotional, physiological and behavioural attributes) that guide action. Second, Greenberg et al.’s approach and PBCT share a commitment to a view of self as process, rather than self as entity, and both approaches are premised on the potential for transformation through harnessing the self-constructive process.

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All enactments involve as a first step in Chair 1 experiencing an NSS, and then decentring from this experience but holding it in mind by moving to a second chair. Two-chair methods are powerful experiential enactments of decentring from NSS, because the person first is immersed in the NSS and then literally as well as psychologically takes a step back. For many people an NSS is so ingrained that this process of separating from it is challenging: as Robin said, ‘It’s a profound thing. It’s digging it out. It’s not you. You realise how there is only one person judging me, and that’s me … now I can jog alongside it – it’s there, but I can say, “I know you, it’s you again, I recognise you now. And you’ve done enough damage in my life.” ’

Taking a Metacognitive Perspective on NSS For many people negative schematic experience has become so habitual, or fossilised (Vygotsky, 1978), that the person has long since ceased to be aware of how it is effortful, and how it regulates mood and behaviour. Clients are often attached to their NSS or critic, holding a metacognitive belief that it holds the key to them becoming better, happier people, if only they could meet its demands (which is, of course, impossible). Twochair working is useful in moving away from metacognitive beliefs like this one, that support distress, and generating new metacognitive insight about the NSS, or critic. In the transcript that follows this process is illustrated, where the client moves from seeing the NSS/critic (manifest in voices and self-criticism) as ‘Strong, cruel, correct’ to being a burden, prejudiced and a disappointment. The NSS is expressed very briefly before moving to the second chair, because the client has already had a bruising time experiencing it that day. The following case example is of a mother, Jo, with a young daughter, Jenny. She hears voices that tell her she is to be harmed or killed, and is hated by everyone. This triggers an NSS. Jo feels very anxious and paranoid when she drops her daughter, Jenny, off or collects her from school. Jenny recently went into care when Jo’s psychosis required hospitalisation – her worst fear is losing Jenny again. Essentially she believes that other parents look at her in the playground and believe she is different, weird, dirty ‘psychologically’, and a poor mother. She believes that the other mothers discuss her and wish her harm. She feels very self-conscious, and finds it almost impossible to speak to other mothers when they do initiate conversation. She hears voices underlining their hatred and malevolence, and has intrusive images of a past trauma. The conversation begins at this point. T: How did you feel standing there this morning? J: Pathetic. Weak and pathetic. Everyone looking and talking. I can’t even take my little girl to school. T: Were the voices saying anything?

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J: Yeah, that I’m weak, pathetic. That everyone at the school hates me. That I don’t deserve to have my girl back. T: That’s your worst fear, isn’t it? So you’ve a lot on, standing there in the playground. Paranoia, anxiety, fears, voices criticising you. How were you feeling? J: Awful. Why can’t I be normal, why can’t Jenny have a normal mum like the other children? T: You were thinking that you are weak and pathetic? (Client agrees) Did it feel like some of the things you do are weak and pathetic, or you as a person? J: All of me. I’m just like ‘Ugh’. Like the feeling you get when you see dog shit on the pavement. T: So there is a part of you that sees yourself as weak, pathetic, like shit. Even at the time, seeing yourself in this way. Is that right? J: Yeah. And I think others think it too. The mums avoid going near me. T: What do you think about that critical bit of you that thinks this about yourself? J: I don’t understand what you mean. T: (Laughs) No, I didn’t understand what I said. What do I mean? (Pause). What I’m trying to say is that there is a part of you thinking these things about you. Thinking that you are like shit. You believe others think it, but actually they don’t say it. You think it to yourself. J: The voices say it, too. T: Right. The voices say it, and you say it to yourself. Can we stick to the part of you that is judging for now? We can look at the voices again later. (Jo agrees) There is a part of you that is very self-critical, and is disappointed – even contemptuous – of yourself. Is that right? J: Yeah, that’s right. T: Well let’s try stepping back now. Would you be willing to move into another chair for a few minutes? It may help me to explain this a bit better. (Jo moves) Thanks. Right, let’s say that the self-critical bit of you that is always noticing what goes wrong, that is always putting you down, let’s imagine that it’s been left in that first chair. How would you describe that part of you? J: Strong. Cruel. Correct. Like my stepfather. (Therapist has already noted in prior session that self-critical voice echoes stepfather, and leaves this for the moment) T: And the bit of you that is over here is the bit that is being labelled as weak, pathetic, like shit. Is that right? (Jo agrees) Okay, I’d like to talk to this part of you here in this chair, and see if we can leave the critical bit over there for a few minutes. When you have to drop off or collect your daughter, how do you feel beforehand? J: Frightened. Anxious. I smoke a lot. I’m ratty with Jenny. I don’t want to go.

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T: You’d like to not take her. Why don’t you just stay at home? J: She needs to learn. She needs her friends. I need to show that I can look after her. T: How many days a month, roughly, do you find that you just cannot get her there? J: I get her there, even if we are a bit late sometimes. T: So you are feeling frightened, anxious, even before you set off. What’s the feeling like on the journey there? J: It gets worse. I start to imagine the faces of the other mums. I feel like getting very angry and swearing at other people. T: And when you walk into the playground? J: That’s the worst. I think they are all looking, saying, ‘It’s her again. Look at the state of her. Who does she think she is?’ I feel so ashamed and dirty. T: And that part of you sitting over there. That critical side of yourself. What’s that doing? J: Oh, it’s telling me it’s my fault. That I’m pathetic. That they all hate me. T: Back where we began, yeah? That critical voice saying these things. But in this chair we have the mum who struggles through fear, worry, shame, to get her daughter to school. You do this because you love your daughter, you want what’s best for her, and you want to keep her with you – show that you can look after her. How much effort does that take every day? J: I’m exhausted when I get home. T: It takes a lot of effort. J: It takes all my strength. Some days I go back to bed, I don’t do any housework. I don’t do anything until pick-up time. I don’t cook tea. Sometimes I just sit in the chair and cry all day. T: So, you exhaust yourself, you struggle every day. You show enormous strength to do this, to resist the urge not to take Jenny to school. And you do this for Jenny. Does the critical voice in the first chair see this side of you? J: It never sees it. T: Does it ever compliment you, or recognise when you do things well? J: It has nothing nice to say. T: It seems to me that this bit of you is very strong. It struggles every day to do this, when it would be understandable if you gave in. You have struggled and worked so hard to get well enough to have Jenny back with you. What would help you during this time? J: Someone there with me. To talk to. To make me look normal. T: And what’s it like having the critical voice over there (points) putting you down all the time? Does that help? J: (Laughs) No, it makes it harder. It seems to use up my energy that I need to get through it. T: So the critical voice is a drain on you. It works against you. It means that you have to work even harder. It means you feel more upset and distressed. And it’s been there how long?

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J: All my life. When I was a girl at school. At home. T: If you could change that critical inner voice into something else, what would it be? J: I’d like it to be supportive. To tell me that I can cope. That I will get through it. That I will keep Jenny. T: Say what you would like to say to that critical voice over there? J: (Turns to chair) Fuck off. Either fuck off or help me. Stop telling me the same things. Leave me alone if that’s all you can do. I don’t need it. T: So in a way that critical voice is a disappointment to you. It adds to your problems. It doesn’t give you what you need. It seems to me that the critical voice doesn’t really understand you. You are not weak and pathetic. On the contrary you show real courage and effort and strength every day. You fight to overcome your problems every day. And every day you get Jenny to school. It’s almost like the critical voice doesn’t really know you, the real you. It’s like it cannot see the part of you that is strong and loving and courageous. That critical voice does not see any of this. Maybe the critical voice is an unwanted burden and a disappointment to you. Greenberg et al. (1993) stress the importance of dialogue between the two chairs. This is a powerful method. Here where the aim is to establish a metacognitive perspective on the critic, dialogue is not used but may be used as the basis for future enactments.

Balancing Schematic Meaning Linked to Abuse One of the most potent sources of NSS is abuse or trauma. In this section I describe using two chairs to bring into awareness some attitudes and feelings that contradict the negative schematic meaning, but are rarely in awareness. Again, it seems that part of the value of the two-chair method lies in delineating but keeping in awareness the NSS, thereby creating space for alternatives. The goal is to help people who blame themselves for abuse to articulate and express an alternative perspective which does not involve self-blame, and has experiential validity. The goal is not to destroy or get rid of the NSS, but to bring it into balance with other perspectives. This has similarities with drawing out a PSS (see next chapter). The following dialogue with Val begins with some exploration of the NSS, which is perhaps too direct and is experienced on this occasion as confrontational. V: The voices are saying it was my fault. He wasn’t to blame. I am. It was my fault. T: That’s what they are saying? How do you feel about it? V: It was my fault. T: So, you believe that the sexual abuse you experienced, and which began aged five, was your fault. You believe that a child of that age can be responsible for that kind of experience?

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V: T: V: T:

(Looks angry) I was to blame. Not others. Just me. Okay, so for all other children, who would be to blame? The abuser. The person who hurt them. He’d be to blame. For other children you’d blame the abuser. But not for yourself. With other children, why would you blame the abuser? V: Because he’s the adult. (Silence. Again, appears to be hearing a voice.) V: T: V: T:

V: T: V: T: V: T:

V: T: V: T:

V: T: V: T:

There’s no point. (Pause) I can’t explain (Silence). Would it help if I recap? Yeah. Okay. We are talking about sexual abuse. You say that you were to blame for what happened to you, though you were only five when it began. With any other child, you would blame the abuser. I asked why, with other children, you would blame the abuser. Because I’ve seen my niece, when she was five. She’s so innocent. (Again, appears to hear voices.) Are you hearing voices again? What are they saying? That you are dangerous. Telling me to run. Would you like to end the session here for today? No. Okay. Are you okay if we continue exploring the abuse? I think we are hearing only part of your experience of being abused – a self-blaming part. I think there is another perspective that it might help to express, but I think I’m maybe being a bit challenging, which is not helping, so sorry if that’s the case. Would it be okay if we used two chairs again? You remember we did this before? I think it might help us explore this without it feeling challenging. (Val agrees.) The chair you are in now. It’s where the voices belong, too. In this chair, how do you experience what happened? The thing is I’m evil. It was my fault. I went to him. I should have stopped it. How do you feel sitting here now? Horrible. Dirty. This is the perspective we know well – that you are bad, responsible, dirty, to blame. Okay, would you move to the other chair? (Val moves.) The selfblaming, critical perspective is there, and if you need to, you can move back to that chair. What I’d like us to try now is to allow other aspects of the experience to be felt. Is that all right? How did the abuse begin? I went to his room. I went to see him (said in a self-blaming tone). Why did you go? Because I wanted a cuddle. I was feeling lonely and scared, missing Dad. Okay. So you went to see him because you were lonely and scared, and wanted a cuddle. Comfort. I guess you’ve seen your niece do this sort of thing?

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V: Yeah. T: How did you feel when he began touching you in a sexual way? V: Scared. Frightened. I didn’t know what he was doing. I knew it was wrong. T: Did you want him to do what he did? V: No. I hated it. (Pause) I hated him. T: What did it feel like physically? V: Painful. T: Did you want him to keep doing this to you? V: No. I wanted him to stop. T: Do you think he knew that you didn’t want the sexual contact? V: Yeah. He said he was punishing me because I was evil. I thought he must be right. T: Did you tell someone, your mother or someone? V: He said she’d blame me. That she’d hate me. T: So let’s summarise. You went to him for comfort, because you were lonely and scared. He touched you sexually, knowing that you didn’t want this. You hated it. It carried on because he told you that you would lose your mother if you told her about it. Who was to blame for the abuse? V: Him. Bastard. (Pause) He’s pathetic. I see him now and I despise him. I hate being alone with him. He keeps buying me things now. I think he’s trying to make up for it, buy me. I take them, the presents, why not. T: That’s right. He was to blame. What has it been like not being able to talk to people about it over the years? V: Terrible. I hoped my mum would know.

Accepting NSS as an Emotional Experience of Self, Not the Self For the majority of clients, NSS are experienced as ‘the self’, rather than as experiences of self. Chadwick et al. (1996) identified a key challenge in CT for psychosis as the conceptual step of recognising that schematic and symptomatic beliefs are Bs, not As, within the ABC framework. This important metacognitive insight is not the same as weighing evidence for beliefs, or evaluating usefulness or impact. There is an even more fundamental question at issue here, namely: are NSS facts (i.e. the self), or learned, emotionally charged experiences of self? It is a process of reappraising not the content of schemata, but their very status. It is an aspect of therapy that is easily neglected. Val (see Chapter 9) wrote the following notes after two sessions devoted to this metacognitive insight. If I turn these facts about myself into beliefs, it means I have got to see these judgements as changeable and have the responsibility of changing them. Don’t these ideas protect me? What will I do without them? All these things I’ve been too scared to do in the past. What about my abuse? Was it my fault? Am

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I dirty? Is he to blame? If I change these facts will I have to get into a relationship with a man? Fear of mother’s rejection – not a fact? But a belief – maybe she would reject me but she probably wouldn’t die because of this rejection. GOD I HATE WRITING THIS. As I am writing this I am crying – I’m so scared of the future – change. No, things aren’t beliefs, they are facts. I’m bad, I’m evil, I’m dirty, I’m murderous. If not, why have other bad things happened? The voices are strong and as ever, negative. I can’t ignore them much longer. I think I’m going mad.

As is clear, reappraising the status of schemata can be a difficult process for clients. Indeed, as people make a breakthrough and come to experience an NSS as part of the self, not the self, there can be an intense emotional struggle. This exploration began after several months of therapy, when the therapeutic relationship was strong. Therapists need good supervision, also to retain confidence in their clients and to keep in mind that the intense anxiety present in the first writing passes. The tone in the second quotation, written two sessions after the first, reflects this. The beliefs that I’ve held all of my life actually that – beliefs, not facts? Is the chair a chair (a fact) a belief? We may have the belief that the chair is ugly, just that – a belief – this is an opinion – this chair is ugly to some, good looking to others. This is a belief – but what we cannot get away from is that it is a fact that it is a chair – no matter what differing people have differing beliefs/ opinions about its looks. If these facts that I hold about myself are relegated to beliefs then there is the scary possibilities of these ideas being changed. I’ve lived by these precepts all of my life. It could even be said that I am cosy with them. I’ve learnt how to act, react, behave, misbehave and protect myself, with these facts.

Acceptance of the NSS means recognising it as part of the self (two-chair methods embody this physically). The same client illustrated this point well. In one session soon after the above writing, we used a ‘self-construction kit’ (Val’s joke) – a nearby empty Wallace and Grommit cake box and a pad of yellow sticky notepaper. She wrote ‘I am bad’ and ‘I am inadequate’ on two labels and put them on a second, empty chair, to represent the NSS. The cake box was placed on a coffee table and we agreed to put in the box all positive qualities she or I experienced in her. Whosoever came up with an idea, for it to go in the box Val had to feel it applied to her. Moreover, it did not go in until the wording was right for Val. I put in the first sticky (‘you are a writer’) and thereafter we took turns. Twice Val said ‘this is really exciting’, looking and pointing at the box. At the end of the process, I asked Val what she wanted to do with the NSS labels on the empty chair. I had expected she would screw them up and throw them into the rubbish bin. Her response surprised me but taught me something very important. She leant forwards, took them from the chair. She tore each in half. One half she screwed up and threw in the bin, the other she put in the self-construction box: ‘They are part of me,’ she said, ‘but only part.’

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WORKING WITH PSS Work in all domains of the ZoPD is a balance of focusing on distressing experience, and on positive strengths and attributes. A PSS is first and foremost an emotional experience of self, with implicit and explicit meaning. Such experiences are transformative when both the emotional and cognitive aspects are brought into awareness (this process is illustrated below in a therapy transcript). Positive emotional experience of self are typically not experienced with clear awareness by people with distressing psychosis, because they are so quickly and easily snuffed out by voices, paranoia or negative schematic thinking. This prevents the inherent unconditional self-acceptance shaping the symbolic self. In Chapter 7 I discuss how to elicit PSS by isolating ‘markers’ (brief positive experiences of self) which are used as the basis for full expression of a PSS through two-chair enactment. When drawing out and strengthening positive emotional experiences of self, therapists need to have a clear conceptual framework for what they are doing and why. Is the goal simply to cheer someone up? Is it to tell them that the cup is half full, not half empty? One crucial point is that a PSS is not the mirror image, or opposite, of a NSS. The mirror image of a NSS is to believe that you are always and forever perfect, completely lovable, good, etc. – what might be called a superior self schema. With a NSS I believe I am just about the worst person alive and with the superior schema I believe I am just about the best person alive. Both reflect the same underlying assumptions and rules, which make a person’s self-worth conditional upon certain outcomes. A PSS is a different perspective on self-worth, one based in equality.

Maintenance and Generalisation of PSS To support generalisation and maintenance of PSS two-chair enactments are repeated using different positive markers. Following Greenberger and Padesky (1995), we encourage clients to keep a data log of positive schematic experiences, however fleeting. Also, therapists explore with clients how they might access the PSS, and the learning from the two-chair method, at times of difficulty. One client originated just such a technique. As soon as he became aware of his negative self-schematic experience, he would rub a chair of any kind (e.g. sofa, seat on bus). This physical prompt brought to mind the PSS ‘lived’ during two-chair enactments, and re-established a more balanced sense of self. Working to support generalisation and maintenance of PSS needs to be a free creative and collaborative process. Einstein said, ‘You cannot solve problems with the thinking that created them’, and creativity exercises help people to break out of familiar cognitive grooves. For example, I

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encourage clients to take a ‘role excursion’. Clients begin choosing a person they really admire – it can be anyone at all, from a grandparent to Martin Luther King. Clients would then spend a few minutes thinking about the reasons they admire this person, what qualities the person embodies, and really absorbing themselves in their perceptions of the person. Then with support clients consider the question ‘how would my chosen person address the question of how to strengthen my experiences of the PSS?’ What these exercises do is help people access and utilise in themselves exactly those qualities they most admire in others.

PSS Express Core Potentiality In Chapter 2 I followed Rogers in describing a positive fundamental assumption about people with psychosis, namely that clients’ core is a positive potentiality to move towards self-expression and self-acceptance, when under supportive therapeutic conditions. The PSS – the positive emotional experience of self – is an expression of this core. It is an expression of Rogerian acceptance of self and others, based in a humanistic view that self and others have equal value. This equality, or unconditional acceptance, is one of the hallmarks of true Rogerian acceptance, and of a PSS. Also, it is how mindful awareness has many of the qualities of a PSS. It is very powerful for people with psychosis to recognise that the voices, paranoia, images and so on are not their core.

WORKING WITH UNDERLYING INTERPERSONAL ASSUMPTIONS A vital aspect of working in the schemata domain of proximal development is working with underlying assumptions, or rules. These implicit interpersonal rules, with linked behavioural strategies, express conditional self-acceptance. All NSS include implicit rules or assumptions – these are conditional shoulds, musts or demands. They express learned interpersonal strategies which serve to avoid recurrence of painful formative experience. Rules tend to relate either to attachment issues or autonomy (achievement and self-efficacy, see page 120 for further discussion of this difference). Underlying assumptions are absolutistic (i.e. musts or shoulds) and make self-acceptance conditional. Positive schematic rules express unconditional self-acceptance. They have implicit goal-seeking and distressavoidance faces. For example, a client subjected to criticism and rejection earlier in life might hold a rule expressed in goal-seeking terms as, ‘To feel acceptable, I must never be criticised or rejected’. The same interpersonal dynamic could be expressed in distress-avoidance terms as: ‘if I make

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demands on people, they will reject and humiliate me’. Tied to rules are interpersonal behavioural strategies for goal seeking and distress avoidance. That is, rules are visible through interpersonal strategies to avoid feared repetition of past distressing experience, and achieve those conditions that must occur for self-acceptance. Distress-avoidance aspects of rules can concern not only avoidance of psychological/emotional harm, but also physical danger. Safety rules I view as somewhat different from classical interpersonal rules, because it is not self-acceptance that is at stake, but survival. Where self-acceptance can truly be unconditional, personal safety does depend on others. Alternatives to safety rules need to be realistic and reflect the degree of real risk the person wishes to take (this is addressed in the two-chair transcript in Chapter 7).

Metacognitive Insight into Underlying Interpersonal Assumptions Underlying interpersonal assumptions, or rules, are expressed in and visible through consistent patterns in interpersonal behaviour. A first task is for therapists to use supported discovery to help clients recognise and articulate the interpersonal rules that are written in their behaviour, thereby making them explicit. Take, for example, a client with an implicit rule ‘In order to accept myself, I must have others’ approval’. This rule would be apparent in a person’s reaction each time he anticipates or encounters what he perceives to be criticism, rudeness or lack of respect. This will be experienced as a fundamental threat to self-acceptance, and provoke a range of behaviour – perhaps an aggressive ‘get in first’ critical and confrontational stance with others, or perhaps a depressive, ruminative withdrawal and shame. Clients are then supported to gain metacognitive insight into the function and regulatory influence of rules. The content of rules is such that they appear to hold the key to gaining acceptance – be it through harder and better work, or establishing the right kind of relationship. Therefore many clients view rules not as problems but solutions. Yet as metacognitive insight grows, clients observe how negative rules invariably produce striving, anxiety and non-acceptance – of self, others or both.

Challenge the Conditional Rule The third step is for the person through supported discovery to decentre from the rule and challenge it. This involves goodness of fit, and all standard CBT methods are very helpful here. It helps to ask questions: Where is the evidence that everyone must respect me? What would you say to a

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Figure 6.1

The Crap or Perfect ruler

friend who related to others according to this rule? How would you help a friend to change this rule? Humour can be very useful with underlying assumptions, partly because they reflect a nigh-on universal human absurdity (we saw in Chapter 2 how therapists hold them about therapy). I well remember one client demeaning her painting of the walls of a bathroom according to a perfectionistic rule. She said how awful it had been. I asked if in any way it might have been done worse: did she paint the furniture by mistake, and the carpets and the glass window panes? Within a relationship that is strong, irreverence for negative rules as they operate now is a powerful intervention (though clearly they would have been learned painfully in the past, where humour is inappropriate). Humour challenges rules by really embracing and playing with the idea of doing something awfully, rather than experientially avoiding such thinking. Presenting clients with materials such as the Crap or Perfect ruler in Figure 6.1 helps maintain and generalise metacognitive insights about rules. Rules can be challenged directly because people do not hold them in the same way as symptomatic or schematic beliefs about the self. They are usually not conscious beliefs at all – they are expressions of contingencies that govern interpersonal behaviour. There is a sense in which rules such as ‘I must always do things well in order to be acceptable’ are actually emotionally neutral, although they prime people for distress and disturbance.

Articulate and Embody a Positive Unconditional Rule for Self-Acceptance: ‘I’m fine whatever …’ The most powerful challenge to a negative underlying assumption is to articulate and embody a positive rule that sits in the same interpersonal domain as the negative one (i.e. attachment or autonomy), where self-acceptance is unconditional. This is the point of the park bench exercise in the shame-attacking section above. Again, the two-chair method described in Chapter 7 helps clients do this, because it can be difficult for clients to articulate positive rules ‘cold’. Robin had struggled to express a positive rule for some time. Trying yet again, he began by saying, ‘it’s knowing that I’m fine, I’m fine whatever happens …’ and then stalled once more, as if there were more words needed. Slowly we both smiled at

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each other, realising that this was the wording for the positive rule – I’m fine whatever happens. Poetry can be a useful medium for positive rules, because it seems to access emotion directly. Therapists support clients to embody the positive rule first in sessions and then outside. Supported discovery and questioning are reminiscent of that used in the ‘magic if’ method used in psychodrama: ‘John, if you were living according to this rule, how would your life be different? What would you do differently? How would you behave in … (use a range of situations where the negative rule creates distress and avoidance)? What three behaviours would most express this rule for you? How would you carry yourself physically? How would you experience your body?’ This discussion then forms the basis of planned behaviour change.

NEGATIVE OTHER SCHEMATA (NOS) While the literature on the construction of selves usually emphasises the fundamental human need for self-construction (e.g. Maslow, 1954; Rogers, 1961), in persecution paranoia (i.e. Poor Me) people find themselves devoting considerable time and effort to constructing their persecutors (it is often argued that the other is constructed in this way precisely to preserve a valued self-construction: Bentall, 2003a, b). The defining cognitive feature of persecutory paranoia is a belief that others are harming the person in some undeserved way (i.e. physical, psychological, or both), and this is usually accompanied by a global, stable rating of the persecutor – a negative other schemata (NOS). Under certain conditions, it has been useful to use two chairs to experience and express a positive construction of another person, and thereby weaken a construction of the other as solely malevolent. These conditions are when there is a specific persecutor, with whom the client has had a relationship, and where the client ruminates extensively on the other’s perceived wrongs. I have not used this process where the client has been sexually abused by the persecutor – under these circumstances we would explore the client’s NSS as above. In conceptual and practical terms, the process is much the same as that for elaborating a PSS. So, for example, one client, David, was utterly caught in a very angry and vengeful belief that a friend had deliberately and maliciously wronged him. He experienced his erstwhile friend, John, as having cruelly, publicly and intentionally rejected, humiliated and harmed him. David judged that prior to this he had helped John considerably, which made the imputed betrayal more galling still. The client was very preoccupied with this, ruminating for hours a day and imagining non-violent valedictory retributions. An increase in preoccupation with this had been a key trigger leading up to his three previous psychotic episodes.

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The method began in the first chair with an experience of the critic, though this time of the other person, John. The client labelled his exfriend, John, a total bastard, listed all the wrongs the person had done to him, how unreasonable John had been. I resisted the interpersonal pull to validate David’s self-construction as victim. I drew out how much the client himself suffered when this schema about John was operating, and empathised with the distress without endorsing the meaning. The client then moved to the second chair. Over the course of about 20 minutes, and with prompting (e.g. Has he always been unhelpful to you, never supportive? Has he ever shown you affection or concern? Was there ever a time when you felt good being with him?), David articulated a very different experience of John. He listed numerous examples of past support and affection (e.g. John had been a particular help and support during two crises in the client’s life). I then prompted David to consider whether there were any times when his own behaviour towards John had been unhelpful. The list was long. At their final 10 or so meetings, David had given John a very full account of his deficiencies and of how much he felt personally let down, wronged and angry. David also gave a list of injunctions about how John should be behaving. Following Greenberg et al. (1993), I drew out a core feeling behind the critic’s anger – though with interruptions from the critic that needed to be managed (see Chapter 7 for managing interruptions in two-chair processes). John had been a close friend over many years and the core feeling was hurt and loss. David was able to express his sadness at the loss, and to express a more accepting alternative schematic belief about his friend. The paranoid belief that John had intentionally harmed him so as to take what had been David’s was balanced by an alternative belief that the problem was more David’s own unwillingness to accept that John’s changed priorities in life (principally, partner and children) had meant that the friendship needed to change. Further CT work then focused on exploring these two alternatives in the standard ways. As with all schema work, this type of process needs to be consolidated in a variety of ways if proximal development is to be maintained and generalised.

CONCLUSION Working with schemata is about two broad types of proximal development – easing distress associated with NSS, and promoting well-being and self-acceptance through development and embodiment of PSS. As in all aspects of PBCT, this process relies on radical collaboration, acceptance of a person’s experience, decentred awareness and metacognitive insight, and experiential methods of change. Working with schemata is a creative process, not a one-off task, and requires ongoing attention to issues of maintenance and generalisation.

Chapter 7

SELF-ACCEPTANCE AND THE SYMBOLIC SELF1

OVERVIEW This chapter describes a two-chair method that spans working in the schemata and symbolic self domains of the ZoPD. In the schemata domain, the method concerns briefly embodying and then taking a metacognitive perspective on NSS. It shows how to draw out and emotionally ‘live’ a positive schematic experience of self – the emotionally charged moments of self-acceptance. The process then moves to addressing self-acceptance at the level of metacognitive insight, by encouraging clients to accept both the negative and positive schematic experiences as valid facets of self. This promotes reappraisal of the symbolic self – a metacognitive perspective on self – which comes to be seen as a complex, contradictory and changing process. To illuminate the process a verbatim therapy transcript runs through the chapter, and I present key themes from qualitative analysis of two clients’ reflections on the method. The two-chair method relies on radical collaboration and is to be used repeatedly, flexibly and creatively to promote proximal development.

THE SYMBOLIC SELF Sedikides and Skowronski (1997) defined symbolic self as a person’s ‘abstract cognitive representation of itself through language’ (p. 85). The symbolic self is closely linked with affect. It has three main properties – to represent a diverse range of self-referent memories and cognitions; to regulate information-seeking, goal-setting and goal-directed behaviour; and a capacity to be conscious of itself (Sedikides & Skowronski, 2000). The symbolic self is perhaps best conceptualised as a set of diverse self-representations stored in memory. These diverse self-representations may not be well integrated, and can be contradictory. These self-representations 1

This chapter draws from Chadwick, P.D.J. (2003). Two chairs, self schemata and a person model of psychosis. Behavioural and Cognitive Psychotherapy, 31, 439–449 and excerpts are reproduced with permission from Cambridge University Press.

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correspond to our definition of schemata – they are what people experience at any given moment (what Sedikides and Skowronski call the phenomenal self-concept). In PBCT the concept of symbolic self equates to a metacognitive model of self. This metacognitive model of self is based in part upon schematic experience of self (i.e. the diverse self-representations mentioned above). Undoubtedly the symbolic self is shaped by experience (Sedikides & Skowronski, 1997, p. 91). While most people probably have moments of negative self-schematic experience, these experiences do not dominate the symbolic self – presumably because they are infrequent and balanced by other, positive self-representational experiences. Understandably the more a person’s intrapersonal and interpersonal experience is dominated by negative schematic experience of self, so too the person’s symbolic self becomes ever more narrow, simplified and negative – what I call onedimensional. My experience is that this applies to very many clients with distressing psychosis. In this chapter I argue that a fundamental challenge of working within a person model is to work directly with the inherent versatility of the symbolic self. This is achieved by (1) bringing experientially into awareness the narrowness of the symbolic self presently (i.e. the person’s acceptance of the global and stable quality of the NSS), (2) bringing into awareness positive self-schematic experience, (3) promoting acceptance of both as experiences of self and (4) working directly to adjust the symbolic self to include these emotionally positive self-representations (schemata) of self and others. There are four steps in this process. First, clients relive for a few minutes a negative emotional experience of self (the NSS), and therapists draw out the implicit quality of globality and stability. Second, therapists facilitate clients to experience an emotionally charged positive experience of self (PSS), including making explicit the implicit meaning. Third, therapists encourage clients to accept in a Rogerian sense both experiences of self, as having an equal phenomenological reality. The aim is neither to get rid of nor reject as ‘irrational’ the negative self-schematic experience. Rather, as the fourth crucial step makes clear, the aim is to see the NSS as simply one experience of self, not the self. Therapists use the clients’ ‘discovery’ of PSS as experiential proof that the self is neither globally nor forever bad, flawed, etc. From here the client is encouraged to explore a symbolic self that is complex, changing and emotionally varied. Therapists emphasise that the client then has real choice – to continue to live by the NSS, or to take risks to develop the positive aspects of the symbolic self.

RATIONALE AND PREPARATION FOR THE TWO-CHAIR METHOD As with all two-chair enactments, the method is introduced in a simple way, with a clear rationale, and clients are given a choice of whether to

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(1) Isolate the marker for two-chair work. (2) Reflect this back to the client. (3) Briefly explain two-chair method and rationale, and seek consent. (4) Brief reiteration of NSS, including global and stable quality. (5) Empathic summary of distressing and disabling nature of this experience of self. (6) Invite client to move to second chair, emphasising that NSS stays in first chair. (7) Client in second chair articulates and ‘lives’, without time limit, a PSS. (8) Therapist facilitates Rogerian acceptance of both schemata. (9) Global and stable quality of NSS challenged. (10) Explore new symbolic self as complex, changing and emotionally varied.

Figure 7.1

Adapted two-chair process in 10 steps

experience it. The enactment in this chapter usually takes 25–30 minutes. The rationale offered is that the process creates a space to explore different emotional experiences of self, including positive ones which ordinarily might otherwise be lost. Clients are told it involves them moving between two chairs. If the person agrees, the therapist would check if the person has any concerns about doing it. Occasionally a client finds the idea of moving between two chairs a little silly or strange. If this occurs it is helpful to normalise any such reaction as an understandable feeling. Ordinarily Steps 2, 3 and 4 take place in the second chair. When the client does return to chair 1 it is useful to check with the person that there is no residue of having enacted the NSS. Figure 7.1 presents a 10-point summary of the two-chair enactment presented in this chapter. In the following four sections I describe how two chairs are used to facilitate each step, with a verbatim transcript, and draw particular attention to adaptations or new developments of the Greenberg et al. (1993) approach (the transcript sections for Steps 3 and 4 are presented in one sequence after both have been described in the text).

Markers for PSS Unlike those two-chair enactments described in Chapter 6, the one presented here involves drawing out an experience of an NSS, and then a PSS based in a different situation – those presented in Chapter 6 concerned drawing out different perspectives around the same experience. When the method is used initially, it is necessary beforehand to have isolated a

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marker for a PSS. Markers are moments of emotionally positive schematic experience that indicate at least partial activation of a PSS. They can occur spontaneously, or be elicited. Typically they will be isolated, brief experiences lasting only a few moments, which are snuffed out by voices or habitual self-criticism. From the first meeting with a client therapists are alert for markers for PSS. Markers from within the session, and even involving the therapeutic relationship, can be especially effective. These are noted and then form the basis for subsequent drawing out experientially of a full PSS in a two-chair process. Markers need to be schematic experiences, rather than merely moments of happiness – in fact, the emotional state may not be happiness. One of the most common mistakes in two-chair enactments is to use as a marker any situation where the person simply felt happy. To check for schematic meaning, therapists probe for self-acceptance, expressed through beliefs and interpersonal rules. In this regard it is useful to have in mind a fundamental distinction between two domains of interpersonal concern, relating broadly to issues of attachment or autonomy (Beck, 1983; Blatt & Zuroff, 1992). Markers should mirror the interpersonal domain of the NSS. So if an NSS related to experiences of the self as unlovable and repugnant to others (attachment), a suitable marker for a PSS might be an experience of feeling warmly accepted and liked by others. Autonomy relates to success and also a sense of self-efficacy. If a negative schema concerned experiencing the self as forever failing and being utterly inadequate, then a suitable marker for a PSS might be a fleeting sense of achievement and self-worth. The central importance of meaning is reflected in the way therapists elicit markers: ‘John, all that you have said so far relates to feeling that others hate you, don’t want you around. Have you ever had an experience, even for a few moments, where you’ve felt emotionally good and secure with someone?’ Again, if markers occur spontaneously, therapists check for positive schematic meaning: ‘John, that experience you described has a very different quality from the norm. It sounds like for a few moments you were able to accept the painting you produced, and even yourself, until the voices started up. Is that right?’ For a first enactment of a two-chair method a clear marker needs to have been identified before beginning. This greatly lessens the likelihood of a client being unable to ‘live’ any positive schematic experience, which could be demoralising (‘even my therapist cannot find anything positive in me, things must really be hopeless’). If for whatever reason a client cannot access positive schematic experience in Step 2 of a twochair enactment, therapists can always fall back on a ‘magic if’ technique from psychodrama, through prompts such as ‘if you did really accept yourself, and feel that you had something to offer the world, how would you have behaved and felt in that situation?’ If using the ‘magic if’ it is still critical to embody and emotionally ‘live’ the experience, asking

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clients to use a tone of voice and body posture that would fit with positive schematic experience, and to express what they might say in the given situation. If markers remain elusive, it helps therapists to keep in mind the assumption that a person’s core is a positive potentiality for self-acceptance (see Chapter 2). The difficulty gives therapists insight into the dominance of clients’ negative schematic experience, and reveals something valuable about the client’s ZoPD. A therapist might say: ‘It’s clear to me just how strong the negative judgements are, how they dominate your life. I can see how you come to feel so distressed and tired. I would feel the same way under this barrage. I want to say that I believe you do have a part of you that is accepting of yourself and others, and I’m still hopeful that we can work together to find ways of getting in touch with it. Shall we spend some time thinking about ways in which we might do this?’

STEP 1: EXPERIENCING THE NSS The first adaptation of the Greenberg et al. method is that in chair 1 the NSS is experienced in the first person (‘I am …’) and not in the third person (‘You are …’). The main reason behind this adaptation is theoretical – it is fundamental in this two-chair method that both the NSS and PSS be enacted as emotionally grounded experiences of self. This is crucial to the subsequent realisation that the self is complex and varied (Step 4 below). This adaptation has a further practical advantage. For many clients the NSS are expressed not only through their own thinking but also voices. The ‘not me’ quality of voices is definitional to the experience (Aggernaes, 1972) and clients ordinarily have an interpersonal relationship with voices (Benjamin, 1989). Asking clients to articulate an NSS in a ‘You are …’ form would place them unwittingly in the same role as their voices (outside the two-chair method this can be useful when teaching clients to use Socratic dialogue with their voices: see Chapter 6). A second adaptation is the experience of the NSS is restricted to around five minutes. This brevity is possible because in PBCT the two-chair method is enacted after the NSS has been collaboratively formulated. Five minutes is sufficient because ordinarily NSS are very present and lived, both in and outside sessions, and supported by experiences such as derogatory voices and memories of abuse. Less than five minutes is likely insufficient to meet Greenberg et al.’s (1993) requirement that the person ‘live’ the critic, and not merely talk about it. Also, if insufficient time is spent living the NSS, clients might infer that therapists underestimate or even fear the power of negative schematic experience of self. This balance thus seems to satisfy Goulding’s (1992) advice that planned experiencing of negative emotions, like visiting a dentist, should occur only when necessary, and be as brief as possible.

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It might appear that Step 1 is an untherapeutic stage, where client and therapist simply ‘wallow’ in misery. This is a mistaken view. While it is true that therapists do not at this stage dispute what is said, or try to bring to mind mood-enhancing counter-evidence, they have specific therapeutic goals in mind. In talking openly about negative schematic experience, therapists acknowledge clients’ day-to-day experience. They also communicate that, at least in their minds, the experience is not so powerful as to be avoided or feared. Also, therapists reflect back the extreme, absolute nature of the negative schematic experience. Of particular importance to Step 1, they make explicit the global and stable properties of NSS that often remain implicit – that at a phenomenological level, an NSS is experienced as ‘the self’: ‘When you experience your self in this way, does it feel like a part of you is rotten, or you as a person?’ or ‘Does it feel like this could be different in the future?’ It really is like ink colouring the whole glass of water. Through their choice of words in reflections and paraphrases, and through Socratic language, therapists implicitly question these properties of globality and stability. When, for example, a client says, ‘I have no good left in me’ a therapist reflection might be ‘so in that moment, your experience of yourself was that you had no good left in you’. This reflection raises the idea that this is an experience of self, not the self, and that it might not apply at all times. Again, when exploring the NSS in chair 1, therapists reflect back how a client’s behaviour (avoidance, self-harm, etc.) is understandable by linking it to the rules: ‘So there’s a really powerful rule, which is saying that you’ll never be able to do anything good or of value, and very understandably you don’t try things – why would you if you are convinced it’s not going to be any good.’ Lastly, Step 1 is an opportunity to structure a person’s negative schematic experience in a clear and containing way that also imparts the cognitive model experientially.

Therapy Transcript: Step 1 The following is a verbatim transcript of use of the two-chair method with a client, Val, used with permission. We had used the two-chair method once before, to work on a traumatic experience (see Chapter 6). T: Val, we were talking just now about an experience you’d had this week of being with somebody else and the voices kicking in and you just feeling really negative about yourself and about being with somebody else. And it sounds like the experience is quite common. V: Yeah, it happens a lot, yeah, in lots of different situations. T: And how do you feel at those times? V: I feel scared, and I feel sad and worthless. Like anything I might say or do wouldn’t be any good for anybody else.

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(Silence) T: So a very painful mixture of emotions – scared, sad, feeling worthless, and just a kind of sense that anything you say or do won’t really be good enough for the other person. Yeah? V: That’s right, yeah, it might even harm the other person. T: It might even harm the other person. V: That’s right, yeah. T: I’d just like to take a minute or two just to think about whether there’s been any moments, when you’ve been with other people, that in any way haven’t felt like this – indeed, that almost felt like the opposite, where meeting other people is not about, obviously, you know, fear, sadness, worthlessness, a feeling almost of people hurting one another – but whether you’ve had even just brief moments of being with other people where it’s felt kind of safe, and supportive, and validating? V: Yeah, there have been some moments like that, it’s not all bad, my life’s not all crap, but a lot of the time it is. But no, there are some good moments of being with people and enjoying their company, and I think they’ve even enjoyed my company, and I might have said something clever and nobody took the piss. T: What I’d like us to do, if it’s okay with you, is to use two chairs, which we’ve done before, to try to look in more detail at these positive experiences of your self and others, because I think what tends to happen is that they are easily lost and the kind of negative experience of self and others can dominate. V: It does. It overrules all the good parts. T: Right. So that I think is a really good rationale for trying the two chairs – that what I think tends to happen is the negative experience of self overrules the good parts. So what we’ll do is begin in the first chair spending up to five minutes just trying to recapture the main points of what it’s like to have that negative experience of self with other people. I hope that’s okay. I know it can be distressing for you. (Val assents.) As I say, we’ll try to limit this to five minutes, and if you find that you become too upset, just let me know and we’ll stop that. V: Okay. T: Having done that we’ll move to the second chair where we’ll try and really draw out some of the details, and the feelings and the quality of that positive experience of self with others. And then what we’ll do after that is we’ll spend some time reflecting on the two. The reason for doing the negative first is that experience suggests it just seems to create some space for the positive one. It seems to allow that to happen better. Is that okay? V: That’s fine, yeah. T: So we’ll spend just up to five minutes just trying to capture some of what it feels like to have that negative experience of self with other people.

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V: It feels depressing and frightening. You’re always scared that somebody’s going to attack you. For even the slightest thing that I’ve done wrong. And sometimes even the slightest thing that I do wrong might not even be in the wrong, but I just feel that the voices tell me it is. T: So, very depressing and frightening. It sounds like what’s driving the fear is a kind of fear that someone might attack you even for the slightest thing that you’ve done wrong, or even at times when you yourself don’t judge that you’ve done anything wrong but the voices tell you you have. V: They tell me I have, yeah. T: What’s it like to be with other people when you are fearing this kind of attack? V: It’s very difficult because I don’t know what some people are going to say to me next. Sometimes I hear them saying things and I don’t know if it’s really them saying it, or the voices again. Sort of derogatory and ‘She’s all bad, there’s nothing good left in her, she’s useless, she’s worthless, this is all she is’. So there’s no positive things out of them at all. T: So very difficult to be with other people, very unpredictable, not knowing what people are going to say next. And it sounds like the kind of … the sense you have when you are in this negative experience of self is that others judge you as bad. They think there’s nothing good left in you, see you as worthless. V: Yeah, it makes me very sad. T: When you are in this kind of experience of self – you are with other people, the voices are driving home these very negative messages of how others see you, and there’s fear and sadness – how do you experience your self at these moments? V: As worthless. That I can never change. Anything I do, even if I think I’ve done something good, is not going to be good in the outcome. It’s going to be rubbished. It’s like I’ve got nothing left to offer people, and it’s quite important to be able to do that. T: So understandably given the kind of weight of pressure that you are under, what seems to happen at those times, is that you experience your self in the same way that the voices are telling you others experience you, which is as kind of worthless. And it sounds like that’s an experience of you as a person rather than just a part of you. V: It’s the whole of me. T: The whole of you. And you are saying that your sense is that it can never change. V: No. T: That in a way you have nothing left to offer other people, that’s how it feels, yeah? And that anything you do is going to be rubbished by them. V: Yeah, I’ll never be able to do anything that’s any good, anything of value. (Pause) And I end up not trying in the end.

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T: So there’s a really powerful rule, isn’t there, which is saying that you’ll never be able to do anything good or of value, and very understandably given that strong driving belief or rule, you don’t try things then? Yeah? Because why would you if you are convinced it’s not going to be any good. (Pause) And also it sounds like there’s a fear, when you are with other people as well, Val. V: I am scared of other people. Even if they look at me, it’s like they are trying to look at me to harm me. And if they come near to me or touch me … (shakes head and torso expressively). T: So a very strong fear that other people’s intention is to harm you, yeah? Which again is a kind of rule for living, or being with other people, isn’t it. That if I get close to people … V: They’ll destroy me. T: Right, okay. So how does that impact on you, that belief that others want to harm or destroy you? V: Again, it’s frightening, and it makes me feel very isolated. T: Right, so you feel isolated, cut off from others. And my guess is that there would be a tendency to avoid other people if the belief … V: I do avoid others. I keep away from people. If people come to the house I go out or go to my room. Or if I’m out in a social situation in a pub or something, I just go outside.

STEP 2: ARTICULATING AND EMBODYING A PSS A significant adaptation of the Greenberg et al. method has been to use two chairs to elaborate not only an NSS (critic) but also a PSS. In the Greenberg et al. method, the goal is to integrate two conflicting aspects of the self; therefore the client begins in the second chair by articulating what it is like to be on the receiving end of the critic (who has already addressed this second chair in the ‘You are …’ mode). In the adaptation the client instead begins in the second chair to articulate fully – and usually for the first time – a positive schematic experience of self. This process is grounded in a positive emotional experience of self. Again, the first-person form is used. In PBCT both chairs are therefore experienced as ‘I am’. Again, as when elaborating an NSS, it is important to avoid a logical or intellectual construction of a PSS – what might be called ‘I must be good because …’ reasoning. The client’s experience in the second chair also needs to be ‘lived’ and founded in emotion. At this stage, the therapist tries periodically to encourage a metacognitive perspective on the first chair, while keeping the two experiences separate (see Chapter 6). This is achieved by regular linking statements: ‘So in this chair being with others is a comforting experience – when you are in the other, being with people is isolating and cold.’ This avoids either the negative experience flooding the client and overshadowing the positive

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experience, or the client feeling that the NSS has been lost in some way (they are valued by clients). In Step 2 I limit dialogue between the two chairs as the primary conceptual and therapeutic task is to elaborate a PSS. Full elaboration may take two or more uses of the two-chair method. Crucially, experiences in the second chair need to be realistic, not ‘puffed up’ (see Table 7.1, below). Step 2 can be challenging because in psychosis the experience of self is so often overwhelmingly negative. The therapist is alert throughout the elaboration of the positive experience of self for any negative self-criticism, which belongs in the first chair. With psychosis, an interruption can take the form of a derogatory voice that asserts negative judgements associated with the negative experience of self. When this occurs, the therapist makes a judgement about what to do. This judgement adheres to Greenberg et al.’s rule of thumb about when to follow and when to direct. If a client is experiencing and expressing important positive experience, and the critic intrudes, then the therapist typically points this out and encourages the person not to be diverted by the intrusion, which belongs in the other chair and can be articulated later. If, however, the PSS is no longer vivid, then the therapist observes that the critic has just spoken and says something like ‘I notice that your last comment belonged in the first chair – the critical chair. Did you notice that? Would you like to return to that chair and spend a little time on this? Or would you prefer to remain here and experience the positive self?’

Therapy Transcript: Step 2 T: Val, we’ve spent just over five minutes and I think, you know, we’ve drawn out what feel like the main features of this negative experience of self. They certainly chime in with what we looked at before. Is it okay with you at this point if we move to the second chair? V: Yup, here goes (moves across). It’s higher (laughs). T: Does that chair feel okay as it is? V: Yeah, it’s fine. T: What we’ve talked about in the first chair is still there. That negative experience of self is still there. What we are going to do in this chair is try to focus on a different experience of being with other people. And if you find yourself, or I notice that you are moving back into that negative experience of self, then I’ll point that out, or if you notice it you could kind of point it out, and what you could then do is either move back to that first chair and get back into that experience of self, or we can just note it, ‘oh yeah, I was slipping back into the negative one’, but not go with it and stay with the positive one. V: That’s fine.

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T: Okay, Val, what I’d like us to do here is for you to try to bring to mind an occasion where you’ve been with other people and your experience of your self has been that you have value, that you have something to say and contribute that other people do see value in. It might be that you’ve had that experience only for a few moments, or a few minutes. V: Yeah, only for a few moments, normally. T: Is there an occasion like that? V: Um. Once I went to a church meeting and everybody was going round saying their bit, talking about something – I can’t remember what the subject was – and it came to me and I thought ‘oh no, I might as well die, just get out of the room quick’ but I spoke and they took up what I spoke. And, um, they didn’t really seem to take the piss out of me, or nothing. T: Right, so quite a nerve-racking situation by the sound of it. A lot of people around. V: So many people around just looking, focused on you – on me – and, um, you think, are they going to get up and hit me, are they going to ridicule me? T: So, that’s that familiar first-chair experience, isn’t it? That the expectation from the negative rules is that they will harm you or ridicule you. But it sounds like that wasn’t what happened. V: No, I stayed in it and thought I’m going to say this, what I want, even if they do ridicule me, or anything, or think I’m stupid. But actually I got a good response, people talked to me, joined in the conversation, and they didn’t put me down. So that was real, like you say, a feeling of self-worth. T: Right, so your experience was that people joined in the conversation, kind of engaged with you. V: That lasted for a while, but then the voices come back again, don’t they? T: Right, and then it was sort of back rubbishing you, as it, as we’ve seen in the first chair. Well, let’s – with the first chair still there, it hasn’t gone anywhere, that kind of negative experience of self – but let’s here try to just keep that space for the positive one. So what did it feel like to have people respond in that way, in that engaging way? V: It is nice, it makes me feel good. You feel good and worthwhile. T: So it felt good and worthwhile. In the other chair the experience is that other people when they look at you can only see negative things, bad things. How did the people on this occasion seem to relate to you? V: Well, they didn’t seem to be picking up on all the bad things that I’ve got. They were being positive and helpful as well, as I think they could see I was a bit nervous. So they were kind of prompting me, sometimes, helping me along, taking up a point that I said and discussing it over. That made me feel really good.

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T: You are kind of smiling there as you said that, yeah, so it was a good … good emotional experience of self. And very striking, Val, that in a way some … beginnings of some quite different rules about your relationships with others. So, a sense that, you know, people could see that you were nervous and that actually they wanted to help you. V: Yeah, it’s a new feeling, isn’t it? It contradicts with this chair (gestures to first chair). T: It’s sort of like … yes, it does exactly contradict it, as you say. In that one (indicates first chair) the idea is that they’ll want to harm you, here that … V: They are helping me. (Pause) It wasn’t patronising either. T: And that’s the kind of second rule, isn’t it? That in the other chair, one rule is other people will always want to harm me, a second one is that they’ll always want to kind of rubbish and ridicule me. But here what you are saying is that they actually took up what you said and it became part of their conversation. So a sense that you had something to contribute. V: Yeah, even though – ooh, I remember now – I wasn’t exactly agreeing with a lot of the people when we were talking, but this dialogue was going. So even if it was just sort of an argument, not a heated argument, just an argument, it wasn’t like they were just agreeing with me or anything. But I was putting my view forward quite forcefully, I think. T: And that’s really important, isn’t it? That what you’re saying is that you don’t have to agree with people, that being in this chair is not just about people just being nice and agreeing all the time. You can have differences of opinions, but there’s a sense that somehow they could relate to you as a person very differently from what was happening in the other chair. V: Yeah, even if they disagreed with what I was saying. T: How did they seem to view you as a person during these moments? V: (Pause) Um. I think at first they were a bit surprised actually, that I was talking. But they seemed to, um, understand what I was talking about and valued what I was talking about. They didn’t shout me down, and made me feel a bit worthwhile. T: So your sense of your self was kind of feeling a bit worthwhile, that you have some value, yeah? I’m wondering because in the other chair the experience is, you know, that other people kind of see you as having no value, see you as worthless. I wonder what the experience was in these moments? V: These moments. T: How others seemed to view you. V: I thought they viewed me as somebody who can hold a proper conversation, I’m not completely stupid. And that I had something to offer. T: Right, and when those kind of beliefs are strong – that you have something to offer, that they are interested in what you can contribute, and they value what you contribute and I guess also see value in you, does that leave you wanting to be with others, or not?

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V: That experience makes me want to be with others more, yeah. T: So whereas the other chair supports avoidance of others and fear, this chair supports some kind of wish to be with others. V: It feels better to be. T: Yes. And your experience of your self in this chair. In that chair it’s that you, you know, totally without value, worthless. What’s it like in this chair in terms of …? V: It’s like maybe I have got something to offer. That I am worthwhile. Even if it’s only for a moment. T: And at that moment does your value seem more than others, or less, or the same? V: Well, no, it seems more than it was. T: More than it was there (indicates first chair). And relative to other people’s value, does it seem like you are less valuable, more … ? V: No, it seems like I’m the same value as they are. They see me as equal. T: So a real sense of acceptance, you of others and others of you. And how do you experience your self physically when you are feeling comfortable, more safe, more accepted? V: I don’t feel so sick. When I’m in that chair I feel absolutely sick. And I have more eye contact. I don’t rock … I don’t rock so much or fiddle. T: So kind of physically more at ease with yourself, more comfortable. Okay, just to kind of summarise, Val, what we’ve done there, then, is in the first chair we kind of draw out what’s actually an extremely familiar experience of self, a negative emotional experience of self. What we’ve done here is begun to draw out and hopefully live a little – get some of the emotion, like your smiling – to get some of the emotion that goes with it, to draw out a very different experience of self. One of self as having equal value to others. Where relationships are characterised by acceptance and helping, rather than judgement and harm (Pause). V: Yeah, I have a different experience with others, like I say something … it’s quite good, and … T: Are you hearing the voices now? V: Yeah. T: Do you want to focus on the voices, or carry on with what we were talking about? V: Carry on.

STEP 3: ACCEPTANCE OF THE POSITIVE AND NEGATIVE SCHEMATA One of the many strengths of Greenberg et al.’s work is their emphasis on Rogerian acceptance of different parts of the self, including the critic. This is crucial in PBCT. In Step 3 the therapist therefore facilitates discussion

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of how both the negative and positive experiences, lived in chairs 1 and 2, are enactments of the person’s own, emotionally lived, experience of self. Therapists stress that both self schemata have importance, are grounded in the person’s own experience, and share an experiential validity. This step draws heavily for its power on Greenberg et al.’s preference for experiential enactment of parts of the self, rather than reason alone. Another virtue of the two-chair method is that the two experiences of self literally sit beside each other, embodying a broader definition of self. I place the two chairs side by side, a few feet apart, to embody how they are both facets of self, rather than placing them opposite each other in more combative positions. For Step 3 to be effective, therapists have to demonstrate genuine acceptance of the negative experience of self. It helps to bear in mind a distinction between an experience of self and a metacognitive model of self. The kind of negative experience of self lived in the first chair is, indisputably, an important part of the person’s ongoing experience of self, and will almost certainly remain so for some time to come. So it is accepted as a valid, important experience of self, but not as the self. This point echoes Hayes (1987), who urged clients to add a rider, ‘I am having the thought that …’, to negative self-judgements. The statement ‘There are many times when I experience myself as totally and inescapably bad’ is undeniable. The statement ‘I am totally and inescapably bad’ is invalid because it ignores much of a client’s own experience, such as that seen in chair 2. By accepting the experiential validity of the NSS, therapists thereby reduce psychological reactance (Brehm, 1962) and help clients to accept the value and importance of the positive one. As Greenberg et al. observe, clients do have an investment in the critic and do not wish to lose it altogether. Therapists therefore explicitly accept both experiences, and would typically say that they are not trying to eliminate the NSS. (From a practical point of view, it is doubtful whether schemata can be eliminated.) Indeed, there is no direct challenge to the NSS. This emphasis on acceptance is a central thread in PBCT, be it of self, schemata, symptomatic beliefs or sensations of psychosis, and underpins proximal development in all four domains. In this two-chair enactment, an emphasis on acceptance of the negative construction and guided positive self-construction reframes the problem as being not so much the presence of NSS, as the absence of a positive one. The important work of Fennell illustrates how self-esteem is really a balance of positive and negative constructions of self (Fennell, Self-Esteem Workshop, Southampton, 2002). As PSS emerge, so NSS are brought more into balance, though still likely remain a significant aspect of self. In Step 3 we place less emphasis on dialogue between the two chairs than does Greenberg et al., reflecting the somewhat different conceptual aims. However, dialogue can be useful, and at these times we very much

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endorse Greenberg et al.’s methods. So, for example, the person in each chair might reflect on how it feels to listen to the other self schema being expressed, or might articulate what it would like to say to the other. Again, therapists encourage clients to explore what is good (advantages) and not so good (disadvantages) about each schema. NSS have advantages, usually in the form of some kind of self-protection through avoidance and other safety behaviour.

STEP 4: A NEW METACOGNITIVE SYMBOLIC SELF In terms of the ZoPD domain symbolic self, a fundamental cognitive change facilitated by the two-chair method is that the NSS goes from being experienced as the self, to being viewed as but one experience of self. In the second chair the person experiences (‘lives’) and magnifies a PSS, usually for the first time. The crucial point is that the negative and positive self schemas have the same experiential reality. In short, the two-chair method challenges experientially the assumption that there is one fixed self that is one dimensional. The two-chair exercise shows, in the person’s own words and grounded in the person’s emotional experience, that the negative experience of self is not the whole story. There is positive experience of self, of being with others, of autonomous action. Of course it can still get lost at times, drowned out by the force of the negative experience of self. But it is there and the person enacted it in the presence of another. Again, clients usually acknowledge that while presently the negative experience greatly outweighs the positive, there is no reason why this balance might not shift in the future. Indeed, the therapist would suggest that the two-chair process itself is for many people an example of how experience can change the perception of the self. Similarly, the therapist may bring to mind how the NSS was established and consolidated through traumatic experiences in the past – a further example of experience altering the sense of self. In literally (physically) as well as psychologically distancing themselves from the NSS, clients develop a new metacognitive relationship with it (see Chapter 6). They see clearly its personal and interpersonal impact (see Table 7.1 below). Also, in Step 1 the person will have expressed the global and stable quality of the NSS (that it is the whole self that is flawed and that this cannot change). During Step 4 the person accepts that this is the ‘felt sense’ of the NSS, but has an overarching metacognitive belief that this is inaccurate and not a sound basis for the symbolic self. The method supports a powerful reformulation of the symbolic self as a collection of complex, contradictory, emotionally diverse and changing experiences of self. It can be useful to explore with the client the origin of the positive and negative schemata. Often what emerges is that the positive experience feels

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more authentic, in the Rogerian (1961) sense that the client feels more the ‘author’ of it. The negative schema is experienced as having been imposed by others, through unwanted experiences with others and voices. In contrast, while the PSS is perhaps perceived as less substantial, it has a strong subjective sense of being created here and now by the person, through current relationships. The more the positive self is experienced as authentic, the more the person is motivated to value and develop it (Maslow, 1954; Rogers, 1961), and its substantiality grows.

Therapy Transcript: Steps 3 and 4 T: Okay. I mean, I think the thing that’s really important from my perspective, is that what we’ve looked at in the positive chair, it’s not me telling you, oh well … V: No, that’s it, it’s not you telling me that I should feel this or that, and may feel this or that – it’s me that’s actually experiencing these feelings. And, and they’re valid. T: Exactly, that’s exactly what strikes me. They have a validity. They’re your experiences, it’s part of your life and they have the same reality or validity as the negative experience. V: Yeah, that’s right. P: I think it’s important we have that framework. That in a way both sets of experiences are valid. V: Both real. T: Both real, we accept both. What I’d like us to do at this point is to kind of, just to sort of take a step back in our minds from what’s gone on here. We began in the first chair with what is a very, very familiar experience for you. That somehow you as a person, just washing through you, is no good, has no value, has nothing to offer other people, nothing to contribute. And a sense that that can’t change. So where we began is kind of like an idea about who you are. What I would call a model of self, that says you are all bad, negative, there’s no good left in you. And that can’t change, it can’t even be different. That’s one kind of model of self. But what we’ve seen in the second chair – and the crucial thing is what we were saying a moment ago is that it’s your experience, it is valid – is that there are moments where your experience of yourself is very different, and your experience of being with other people is very different. V: Yeah, there are moments like that. Um. That, as you say, is valid, it’s my experience. That happens sometimes. It’s just as valid as that experience (gestures to first chair). T: Right, and I agree with that. I wonder, though, what that says about that view of who you are, that you are totally bad, there is no value left and it can’t be any different.

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V: It’s quite hard actually to answer that because if I think back in that chair and I think of all the negative things again, and I can’t see any way out. T: That’s really important. So when that kind of experience of self is happening, it just washes over you like a wave. V: I can’t see anything positive. T: But what about now if we are taking that step back in our minds from both chairs and almost looking on? That there are negative emotional experiences of self with others; there are fewer, but still there are positive emotional experiences of self. And they are both your reality. So if we take a step back. What does that say about who you are that they both exist? V: They both exist. This is very hard to admit, I think, because I’ve been so long admitting that it’s all crap and I’m all bad, that this … this kind of leads, if you consider this chair, into me thinking this is not all I am, all bad. T: Right. Right, which is a powerful statement, and it’s a statement about yourself. V: It’s quite a confusing statement. T: Can you say more about that? V: I’m not used to thinking like it. It happens so rarely and it’s overshadowed by the bad bits. T: I think that’s really important. I think oddly enough there is something of … (pause) … comfortable almost, or safe, about a clear view of who you are, even if it’s negative. V: You know how to react. I’ve learned how to react to those situations (indicates first chair) and I can protect myself. In this situation, in this chair I’m unsure sometimes. T: So it’s kind of shaking things up a little bit, yeah? But I suppose what we can take from today’s two chairs is this powerful statement you’ve made that although there is a kind of uncertainty, an anxiety that goes with it, you are more than just that negative chair. V: Yeah. I am. T: I think two things that we can take forward from here – and there may be others you’ll want to add to this as well – but two that strike me. One is to find a way of keeping that space for this positive emotional experience, kind of consolidating it and letting it develop. And the other thing is keeping in mind what we were saying about safety – that the last thing we want to happen from this positive chair is that you would just kind of (smiling) totally trust every single person all the time anywhere. V: (Laughing) That’s not likely to happen, is it? T: (Laughing) That’s true. But there’s a kind of new balance there. What you are saying is the invitation in this second chair is to have a different way of relating, an unknown way of relating. V: I’ll just have to learn how to cope with that way of relating, if it’s going to happen some more.

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T: Does that sound okay with you if we kind of take forward this idea of creating that space still, but doing it safely and, as you say, developing coping? And the other thing I’m keen for us to take forward is this sense that although that negative sense of self when you are in it is utterly compelling – that’s Who You Are – that’s how it’s experienced. V: That’s right, that’s how I experience it. T: But if you can keep in mind that’s not all of who you are, it just feels that way when the voices are strong and the negative emotions are strong. I think that’s another challenge for us, to keep that higher-level message about who you are accessible. V: Yeah, because it’s easily lost.

THEMATIC ANALYSIS OF TWO CLIENTS’ SUBJECTIVE EXPERIENCE OF THE TWO-CHAIR METHOD To provide some preliminary insights into clients’ subjective experience of the two-chair method, and processes of change, two clients agreed to write about their experience. Both had long-standing paranoia and voices. One main prompt was supplied: ‘What was it like to use the two chairs?’ and participants were encouraged to include positive and negative reflections and feelings. Clients wrote in their own time. Content analysis revealed six themes. These are listed in Table 7.1, along with their definitions and verbatim examples. To assess reliability of the coding manual, two clinicians independently rated the transcripts blind; inter-rater reliability was 100%.

FLEXIBLE USE OF THE TWO-CHAIR METHOD It is vital not to imagine that this or other two-chair methods are so powerful as to realise all proximal development in one run-through. There is much to maintain and generalise: to help clients be fully aware in and outside sessions of emotionally charged moments of self-acceptance (positive schematic experience); to consolidate metacognitive insight about NSS; and to reinforce the new symbolic self. To support metacognitive insight, maintenance and generalisation, the two-chair method needs to be seen as a flexible process, not a one-off task, and it will for many clients need to be used several times and flexibly. Once the two-chair method is familiar to a person, it can be shortened. On second and subsequent re-enactments, for example, once a client has gained a clear metacognitive perspective on the NSS, therapists might decide to curtail Step 1 to a couple of minutes only, or even omit it altogether – that is, move straight from a marker to drawing out the positive schematic experience in a lived way, whilst making links and comparisons with the NSS.

Defi nition

Emotional impact on self Impact on thinking (e.g. selection bias) and behaviour Interpersonal impact

PSS has an emotional force, or impact – a felt sense

By using two chairs person gains distance from self, looks on, has space, takes a metacognitive perspective

Appreciation of complex, multi-faceted and changing nature of self

Theme

Impact of NSS

PSS is ‘lived’

Stepping back

Model of self

(continued)

‘You can separate yourself, and you can separate it into many different parts.’ ‘Once you got one good bit, that’s okay, there are always possibilities of other bits. And the negative is not going to be all the time, all my life.’ ‘Earlier on, there seems to be no option but a negative. When the breakthrough happens, it’s quite strange. Surprising. I was surprised. Amazed that there are other parts of me.’ ‘I had always thought there was just that one part of me, a negative one. I thought this all my life. It’s nice to find this isn’t true.’ ‘It [NSS] is a part of me, just not all of me.’

‘Sitting in the new chair helped me to look at myself from the “outside”, which is quite an amazing thing to do.’ ‘It helped to physically shift from being in those destructive, negative feelings, to looking at them from an outside point of view.’ ‘It gives you space to look at the other chair. You can see yourself sat there.’

‘I felt happy in the positive chair and it was important to let this new viewpoint really soak right through me and permeate my thinking.’

‘I realised how badly I felt, how the negative state was no good for me, was not working. Attending only to the negative paralysed me. It was getting me down and eventually it would have worn me away.’ ‘Others often gave compliments which didn’t reach me because I just dismissed them and said to myself, “They are just being nice and do not realise how horrible I really am.” This devalues myself, and the other person who is giving a gift.’

Examples

Table 7.1 Themes identified from transcripts of two clients’ reflections on the two-chair method

View of self is realistic, fits with others’ views, or with experience

Person discusses what it is like outside sessions, and how easily gains from two chairs are remembered, used or applied back in the real world

Realism

Generalisation

‘I knew that I would have to go back to ordinary life where problems do occur. I had to face this. I would need to integrate the new way of thinking into my life.’ ‘After sessions, sometimes it still feels like there’s good in me; other times out of sessions it seems like the two-chair thing just doesn’t seem real, the two chairs, the positive me, that doesn’t seem real.’

‘The positive view should never be false or puffed-up – it has to be based on solid truth. There is no sense or point in lying to myself in the long term.’ ‘The two chairs made me look more closely at what others might see in me when they say positive and negative things to me. This is realism, a breakthrough. It brings a much more accurate picture of myself.’

Examples

Table 7.1 © Cambridge University Press. Reproduced with permission.

Defi nition

Theme

Table 7.1 (continued)

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One client, for example, with a lifelong history of physical harm, criticism and emotional neglect, used the two-chair process for the first time. She found it very easy to live the NSS, difficult to disengage from it, and more difficult still to live a positive experience of self. But she did manage this, feeling how when with a particular friend she had been accepted as a person, encouraged to be herself rather than please others. This took the available time, so Steps 3 and 4 were left over. Over the following week she experienced no moments of positive self-acceptance, and the NSS was actuated often. The therapist felt a little disappointed, and wondered if something had gone wrong. She brought this to supervision. I clarified first that it was remarkable that the client had achieved so much, and emphasised the need to stress this at the next meeting. Second, it was important to help the client process the first two-chair enactment – perhaps by use of a two-chair enactment to gain a metacognitive perspective on the NSS (Chapter 6). Two-chair methods can be interwoven to support proximal development. For some people, the positive schematic experience is so alien that therapists need to create ‘processing time’ at subsequent sessions. This is really a chance to allow meaning to ‘catch up’. So for this woman, it was important to encourage a metacognitive perspective on the experience of the NSS in the first chair – that is, through questions such as ‘what is it like to be in that mode, how much energy does it take, what is it like to spend so much of your life living those messages and emotions?’vv It was important to explore how it felt to disengage from the NSS when moving to the second chair, and where this difficulty lay – while validating her own power to do this. It was important to explore what memory she had of the positive experience, how long it remained accessible and ‘real’ after the session, and what could be learned from this about the way her positive self was lost in everyday life. It was important to reflect on how remarkable it was that the positive self was there at all, after so much external control and criticism and harm by others, and to share the Rogerian idea that we all have a positive core. Having explored all this with the client, Steps 1 and 2 were repeated twice more in sessions, with different experiences, and only at this point did they move to Steps 3 and 4.

SUMMARY This chapter has described methods for therapeutic embodiment of an NSS and PSS that need to be used in a radically collaborative (i.e. flexible and client centred) way and viewed as an ongoing process to support proximal development. The process illuminates how to support new metacognitive insight into the nature of schematic experience of self, and to use this as a basis for metacognitive self-acceptance expressed in a reformulated symbolic self.

Chapter 8

PBCT GROUPS: PRINCIPLES AND PRACTICE

OVERVIEW This chapter discusses how to run PBCT groups – a major part of my own work for the past decade. The main objective when running PBCT groups is the same as elsewhere in this book – to alleviate distress by working in a radically collaborative manner with one or more of the four domains of the ZoPD (see Chapter 3). The chapter has five sections: understanding therapeutic factors, designing a group, assessment, getting started, and running PBCT groups. This chapter refers frequently to Yalom’s (1995) book The Theory and Practice of Group Psychotherapy. This is no departure into group analytic practice. What is so refreshing about Yalom’s work, and gives it a universal relevance, is his total commitment to a flexible and pragmatic search for how to run effective groups. Indeed, while Yalom has much to teach cognitive therapists about running groups, his book draws extensively from cognitive and behaviour theory and therapy when discussing groups for people with psychosis.

THERAPEUTIC FACTORS Cognitive therapists have many skills that are essential for running effective groups for people with distressing psychosis. An appreciation of therapeutic factors is perhaps less intrinsic to our training. Yalom (1995) encourages therapists to keep an interpersonal perspective even when running groups that are short term, or educational, or both. Therapeutic factors, or process factors, provide a language for interpersonal elements of group therapy. Therapeutic factors are not complex, mysterious or psychodynamic concepts – they are like the concept of therapeutic relationship in individual therapy. Table 8.1 presents those eight therapeutic factors that have most prominence in PBCT group work. Each is illustrated with a client statement from Yalom (1995) and a statement from a client in one or other psychosis group I have run. The table also shows the polar opposites of these eight

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Table 8.1 Eight therapeutic factors, with client examples from Yalom (1995), our own groups and their opposites

Therapeutic factor

Examples from Yalom (1995)

Statements from people with psychosis

Opposite process factor

Altruism

Helping others and being important in their lives

Supporting people when their voices are really bad

Feeling hostility towards others

Group cohesion

Belonging to and being accepted by a group

Enjoying us being together

Feeling sense of isolation: ‘Each man for himself’

Universality

Learning I’m not the only one with my type of problem

Finding others also have voices telling them to do bad things

Feeling different and set apart from other members

Interpersonal learning

Feeling more trustful of groups and of other people

Finding my paranoia passed and I could feel safe with other patients

Feeling less trustful of groups and others

Guidance

Someone in the group giving definite suggestions about a life problem

Learning mindfulness to cope with paranoia, images and voices

Finding others’ guidance or advice unhelpful

Catharsis

Learning how to express my feelings

Being able to talk openly about voices for the first time

Hiding important feelings, feeling unsafe

Self-understanding

Discovering and accepting previously unknown or unacceptable parts of myself

Learning to accept voices as a part of me

Increased reliance on old views of self

Instillation of hope

Seeing that others had solved problems similar to mine

Thinking maybe I can learn to live with my voices and paranoia

Feeling hopeless, pessimistic and demoralised

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factors – for instance, while group participation might engender a sense of universality, it might alternatively lead a person to feel completely different and set apart from other group members. Not all factors are necessary for a group to be positive, though cohesion is usually important. Also therapeutic factors are not independent– so if you are able to support key ones, the likelihood is that others will also be experienced. If a group is experiencing difficulties, this can be conceptualised in terms of therapeutic factors. With catharsis, for example, a group might be struggling because of absence of emotional expression because of fearful avoidance. Or there may be a fundamental lack of cohesion that underlies lack of emotional engagement (the real threat to groups is not negative affect, but absence of any emotional engagement). Monitoring therapeutic factors throughout as well as at the conclusion of groups is therefore helpful. Remedial intervention to develop key factors that are lacking in the group is then possible. Bloch, Reibstein, Crouch, Holroyd and Themen (1979) developed an innovative yet simple method for doing so, whereby clients rank order Yalom’s client statements (from Table 8.1) from the most to least helpful. We have used this method to assess process in groups for people with distressing voices (Chadwick et al., 2000b) and in mindfulness groups (Chadwick et al., 2005). It surely adds to understanding from outcome measures to learn that in the five voices groups we ran, for example, clients’ ranking of most to least helpful factors was: universality, catharsis, instillation of hope, self-understanding, altruism, group cohesiveness, interpersonal learning, guidance.

DESIGNING A GROUP FOR YOUR SETTING AND PURPOSE The success of a group is in the balance before it starts. It is far more straightforward to establish and maintain a therapeutic group culture than it is to remedy an existing untherapeutic one. Groups can be designed to support proximal development in any of the four domains of the ZoPD (Chapter 3). If therapists decide that they would like to run groups, it can be hard to know how to go about this. One option is to take an established group protocol ‘off the shelf’. This can sometimes work well, but the risk is that the protocol does not quite suit the particular setting or clients. Yalom (1995) offers a more creative three-step process of designing specialised groups (which includes those for people with psychosis). Yalom’s (1995) Three Steps for Planning Specialised Groups (1) Assess the clinical situation, separating those factors that cannot be changed from those that can. Often what appear to be unchangeable constraints are just habit (‘this is how we have always done things’).

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(2) Formulate appropriate clinical goals. Goals must reflect clinical reality and available time. You may not like the constraints identified at Point 1, but ‘it is better to light a candle than curse the darkness. With proper modification of goals and techniques you will always be able to offer some form of help’ (Yalom, 1995, p. 452). In PBCT, in keeping with radical collaboration (Chapter 2), clinical goals are formulated explicitly in terms of distress and clients’ own goals. This stage is very creative – it is where therapists and clients get to brainstorm and explore an exciting question: what type of group do you really believe would be most helpful to clients in your specific clinical situation? The more creative therapists and clients are, the more likely it is that the subsequent group will inspire its members, including therapists, and meet the specific needs of clients, supporting proximal development. (3) Modify traditional technique in the light of Points 1 and 2. Retain the basic principles and therapeutic factors of group therapy, but alter techniques to achieve the specific goals. ‘In this step, it is important to consider the therapeutic factors and to determine which will play the greatest role in achievement of the goals. It is a phase of disciplined experimentation in which you alter technique, style, and, if necessary, the basic form of the group to adapt to the clinical situation and to the new goals of therapy’ (p. 452).

Balancing Process and Structure The three steps involve consideration of process as well as structure. For example, imagine planning to run a mindfulness group on an acute ward with a quick turnover of clients. This poses questions not only for structure of sessions, but also process – how might group cohesion be maximised given the constraints? Balancing structure and process is the art of group therapy. A conventional unstructured analytic group style is not used in PBCT. Nor is it recommended by Yalom (1995) for people with psychosis, for whom these types of groups are likely to generate anxiety and confusion, and to increase paranoia, voices and potentially risk. Key cognitive and metacognitive insight is also lost unless a group leader uses practical, structured methods for drawing out and making meaning explicit. What people with psychosis need is alleviation of distress, rather than self-exploration, and this requires clear structure. As Yalom states: ‘One of the most potent ways of providing structure is to build into each session a consistent, explicit sequence. This is a particularly radical departure from traditional outpatient group therapy technique,

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but in specialised groups it makes for the most efficient use of a limited number of sessions … a structured protocol for each session has the advantage not only of efficiency, but also of ameliorating anxiety and confusion in severely ill patients’ (p. 471). Yet just as groups can lack structure, so too they can be overly structured, or controlled. When training I experienced an anxiety management group, which was very structured and had the feel of seven lots of individual therapy taking place in the same room. The therapist, who was skilled and compassionate, worked her way round the members in turn, assessing the same points with each – for example, checking on progress with past homework and agreeing homework for the coming week. This tight structure had the advantage of progressing through a predetermined manual efficiently in limited time. However, overly structured groups feel restrictive; clients often talk only about the question asked, and stay within the confines of earlier ‘answers’ to therapists’ questions. Anxiety for those who come late in line to speak can mount as they await their turn. Moreover, communication between group members is limited; clients tend to talk to and through therapists. The interpersonal side of groups is largely lost. The group process in PBCT sits between the two extremes of too little or too much structure. Groups have a clear structure and purpose, and the two are explicitly linked. The style of relating adheres to the principles outlined in this book. Relationships are cooperative, collaborative and empowering. The process of exploring and questioning beliefs uses supported discovery; direct challenge is avoided. Therapists embody and instil: a radically collaborative, open and accepting interpersonal culture; a focus on understanding and alleviation of distress (while neither striving for nor implicitly demanding it: see Chapter 2); an acceptance of commonality and difference among members. Therapists also have lead responsibility for managing the group process, for example, by structuring a group so as to manage anxiety levels early on, or restricting silences by use of summary, reflection, etc. While agendas are set at the outset, there is flexibility and dialogue is open and free flowing, and therapists are responsive to key points that arise.

ASSESSMENT AND SELECTION All groups I have led for people with current distressing voices, symptomatic beliefs, paranoia and images have been run as inclusive, clinical services. I do not have set exclusion criteria. In my experience a thorough and radically collaborative assessment phase is more useful than a list of exclusion criteria. It draws out and offers a chance to work through barriers to group membership, to weigh likely advantages and disadvantages of joining a group, and to identify some ways of coping applicable to

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increasing levels of distress. This involves discussion of several practical issues and assessment usually takes from two to four meetings. Assessments are carried out by one of the group therapists, because clients have said how it reduces their anxiety coming into a group if they know at least one of the therapists. I now discuss some key issues for assessment in turn.

Disclosure Disclosure is a profound issue for psychosis groups. It relates not simply to traumatic experience, but to disclosure of symptomatic beliefs or content of voices – will people judge me, fear me, or laugh at me? It is helpful to discuss openly at assessment the question of what to disclose in a group. The main principle, which I repeatedly state, is that clients are free to decide what to disclose – I encourage ‘freedom of non-speech’. In support of client choice, therapists need to give assurance of confidentiality from assessment sessions to the group – that is, therapists will not introduce in a group meeting material disclosed at assessment. Freedom of choice not only gives the person control, it also draws out any implicit assumptions the person might hold about the need for detailed disclosure. As a co-therapist for two years in a women’s childhood sexual abuse group, I saw how commonly women held an implicit assumption ‘In order to make progress in the group I must describe the abuse in detail’. In fact this type of ‘there-and-then’ disclosure was rarely helpful: it was generally more therapeutic to focus on the ‘here-and-now’ impact of abuse – how they currently experienced men, intimacy, sex, their parents/carers for allowing it to happen, themselves (e.g. bad, dirty, responsible), trust and closeness. In place of assumptions about why ‘I should disclose’, clients and therapists consider likely advantages and disadvantages of degrees of disclosure. Disclosure is not all or nothing. For example, it can be very helpful for a group to hear that a person’s voices began following a traumatic, distressing experience, without knowing what that experience was – or that certain personal comments the voices make are especially difficult to accept, without saying what those are. I seek to establish a group culture that accepts all levels of disclosure right along the continuum, and in my experience people with distressing psychosis are respectful of each others’ choices. This culture of acceptance, choice and degrees of disclosure prevents clients feeling they have failed if they do not disclose everything. Assessment moves clients away from assumptions about the need for disclosure towards the key question: what level of disclosure is likely to be useful for me in this group?

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Of course, detailed disclosure can be useful. One woman I worked with had experienced an extreme degree of degradation, depravity and perversity. It was this that fuelled her silence as a child, in the form of two central beliefs – either no one will believe me, or else they will judge me as perverted and bad for saying these things, regardless of whether they believed me. It was important for her to illustrate once to the group the extremity of the abuse (not all of what happened, which lasted years) so as to test a here-and-now fear of judgement and rejection. She did not feel the need to describe her experience in detail a second time.

Expectations and Aims Just as in individual therapy, I explore clients’ expectations and aims for participation. Therapists are explicit about their limitations. Group therapists cannot solve clients’ problems any more than can individual ones. I seek to establish a realistic context for a group, because instillation of hope comes from clients having explicit, realistic goals. This is in part about checking for unhelpful beliefs and assumptions. With voices or mindfulness groups, for example, it is stated at preparatory sessions that the group will not stop or get rid of voices – and, indeed, that this is not an aim. Also, it is helpful to challenge any idea a person holds about ‘this group being my last chance’, because it reduces the likelihood of a person making a clear choice about whether to join, and probably hints at unrealistic expectations about what might be achieved. Goals relating to ZoPD are as important in groups as in individual therapy. It is important to address how clients, or therapists, think being in a group (as opposed to individual therapy) might support proximal development. Framing clients’ goals in terms of easing distress through working with one or more domain of the ZoPD supports group cohesion by meaningfully linking clients’ goals around a common purpose of reducing distress, and promoting acceptance and well-being. With groups it is important to explore some expectations and aims that are explicitly social or interpersonal – for example, about relating with other group members.

Clients’ Anxiety and Worry Clients often have anxieties and worries that are specific to joining a group. Always in PBCT therapists assume that clients have grounds for their beliefs (see Chapter 4), so it is important to use supported discovery to explore the evidence for these anxieties, including past experience, both positive and negative, of groups. The aim is not to get clients to join a group, which would be an anti-collaborative mode (see Chapter 2), but to collaboratively reach a decision.

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Role of the Therapists In all PBCT I am keen to be open and clear, and to minimise transference. With this in mind, it is important to explore at assessment clients’ expectations about therapists’ behaviour and role in a group. This might be done by asking: ‘Do you have any ideas about what I might expect from you in the group?’ Therapists then can respond to these points openly and clarify their role. Therapists describe themselves as committed to working with clients to alleviate their distress, as being engaged participants in a social group process, not remote experts, and as keen to learn from those present. Therapists say whether it is their practice to set homework in the group and what this might involve. I avoid any labelling of clients. I include in this a style of relating to groups where individuals are ascribed group roles – this person is the group protagonist, and that one is the group carer, or parent. I do not find this type of labelling to be person centred, but rather to limit therapists’ perception of and behaviour towards clients.

Group Rules and Norms All groups have rules, and it is as well to be open and clear about them. They protect all group members and support goals and structure. Therapists are explicit about clients’ responsibilities to the group and to each other: chiefly to be committed to attend, and to treat all other people (including therapists) with respect and acceptance, even if what they say is different or disagreeable. Therapists’ responsibility is to support this way of relating. In groups I have led I have neither encouraged nor discouraged out-of-group contact. Confidentiality is an important issue for clients and therapists alike. Outside a group clients are free to discuss their own experience of being in it, but not to talk about others’ experience. Therapists are also obliged to be open and consistent on this issue. Therapists need to state clearly what rules of confidentiality they typically use, and to check if these are acceptable to the group. Therapists must be consistent with what they have agreed, and if confidentiality needs to be broken for issues of risk, then this needs to be stated beforehand in the group. Beyond issues of risk, I share with other professionals only a general end-of-group record of what was covered, and clients also have a copy. Often in groups I have prepared a weekly summary of what was covered and given a copy to each client the week after. It is important to mention all clients at least once on summaries, and I try to do this even if a client was absent – perhaps by making a link to their contribution at an earlier time. The choice of words is shaped in the same client-centred way as for formulation letters (Chapter 3). These session summaries can

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be useful materials to share with other professionals, subject to client agreement. I urge people not to use recreational drugs prior to attendance. This is not a judgmental stance, but practical. One man who attended a mindfulness group having smoked cannabis and drunk two glasses of Scotch had to leave after only one of the two planned 10-minute meditations, looking distinctly green about the gills.

GETTING STARTED: THE FIRST FEW SESSIONS Therapists can feel anything from apprehension to strong anxiety about starting a new group. In my experience, the two measures which most ameliorate this are, first, adequate planning and assessment and, second, having confidence in clients’ capacity to work effectively with you and each other (a primary stance in PBCT). If therapists provide well-planned groups, where assessment and therapy occur in a radically collaborative way, then clients will work effectively in them. Initial tasks for therapists are to contain clients’ anxiety and to help them begin to talk about their experience. Therapists have in mind certain key therapeutic factors at this early stage: discussion of experience around themes will start to support a sense of universality, group cohesion and instillation of hope. Anxiety levels are typically very high and many people will have thought of not attending (although non-attendance has been low in our groups). Indeed, voices frequently command people not to attend, or warn of dangers for them if they do. In my view it is unhelpful to try to challenge or interpret such statements. It is too early in the process, and would place considerable pressure on the individual concerned. Rather, I would ask how it felt coming to the session given these obstacles (i.e. voices forbidding it) and perhaps explore and validate the reasons behind the positive and autonomous choice to attend. It is helpful to explore how clients felt in the days or hours before the group, and how this impacted on voices or paranoia. This is an opportunity for therapists to (a) affirm members’ attendance as a difficult achievement, often involving distressing bus journeys and perhaps disobeying a voice’s command not to attend, (b) underline any universality (e.g. voices becoming louder and more frequent for those people who felt anxious leading up to the group), and (c) remind members that they have all chosen to attend the group; in no way is there a pressure to do so. Notwithstanding thorough assessment of disclosure, this issue still needs to be borne in mind. Most of the people in a series of CT for voices groups we ran (Chadwick et al., 2000b) had never discussed their voices openly in detail with anyone, not even other clients when in hospital. If the reason for this avoidance does not emerge, therapists might facilitate this: ‘It sounds like you all have avoided talking to people about your

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voices. This includes family, friends or professionals. I’m sure you’ve got good reasons for this. What fears do you have about talking about your experiences to others?’ Not discussing psychosis with others is a safety behaviour intended to avoid one or more of several dangers. These include: making a fool of myself (getting things wrong); being judged or labelled by others (as dangerous, mad or bad); being controlled or punished (e.g. increased medication or hospitalisation); being offered impossible advice (just ignore them); being disbelieved; or causing upset to loved ones. The group can then be framed as a safe place to break the silence: ‘So your experience in the past has been the less said, the better. The opportunity for us here, in this group, is to create a setting where you can be different, can discuss things more openly and feel safe and accepted.’ I have run groups structured around specific experiences, such as voices groups or paranoia groups, as well as groups open to any clients with distressing psychosis. In experience-specific groups, it is important to leave ample time in the first couple of sessions for clients to express their experience and how they make sense of it. At these early sessions I do not offer an alternative perspective, which would close down clients’ exploration and even be disrespectful. In keeping with a commitment to beginning proximal development where clients are now, therapists’ aim is to support discussion, not lead it, and seek to understand. So having first explored anxieties and set ground rules to help contain them, in our voices groups therapists have then facilitated discussion using some gentle prompts around themes of onset (when the voices first began), impact (how it affects the person’s life) and meaning (how they make sense of the voices).

Involvement Clients with distressing psychosis can find it very difficult to speak in groups, particularly in early sessions. It can help at assessment to alert people to this, and say that therapists will help people who are silent and anxious to get involved, with some gentle prompts. In the group, if a person has not spoken at all, or for a long while, I will gently draw them in with simple links such as ‘John, Jane has just talked about the impact of her voices. How was it for you when your voices began? or ‘Does that ring any bells for you, John?’ or ‘I’m sure you have valuable things to contribute on this, John. What do you make of this discussion of fear of voices?’ Of course people do not have to talk regularly throughout every session – if someone is having a quiet week, offer a gentle check-in, make regular eye contact, and refer to comments and contributions the person has made at earlier sessions. At the other extreme people can say too much at early sessions – perhaps going into lengthy disclosure and then finding it very difficult to attend subsequent sessions. Again, it helps at assessment to raise this

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issue, encouraging people to say some things but not too much at the first one or two meetings. We also let people know at assessment that if they have not spoken for a long while, we will try to draw them in with some gentle prompts. In the group itself it is important to find ways of balancing people’s contributions: ‘John, can I just stop you there. You’ve said a lot already about living with paranoia that is really valuable and I don’t want it to be lost. I’d like to bring others in because I think there may well be important connections between your experience and that of others here.’

RUNNING PBCT GROUPS Running PBCT groups requires all the skills described so far in this book. In this section I discuss some issues that are specific, or at least accentuated, in groups, and some adaptations to method that are required.

Meeting People Not Problems Just as in individual PBCT, therapists aim to meet people not problems. In groups this can be supported by having 10 minutes at the start of each session for clients to check in with one another how the last week has been. Also, we have a coffee break in groups, which again is a time to support social contact and conversation. Also, therapists who work in a personbased way are seeking to also be themselves – it is a meeting of people, rather than delivery of a manual. Humour is a very useful pressure valve in groups, and models how groups are not congregations to suffering.

Maintain an Accepting, Balanced Stance Rogerian non-judgmental acceptance of a person regardless of their behaviour is pivotal to PBCT. Acceptance can break down in quite subtle ways in groups, establishing an Orwellian culture of ‘All animals are equal, but some animals are more equal than others’. For example, imagine in a mindfulness group that a client opens a session saying ‘I used mindfulness this week and I was able to sit with my voices, just allow them, observe them, and they stopped after a few minutes of this’. There is a temptation for a therapist to give a buoyant, animated response, saying something like: ‘That’s really excellent, well done, thanks for that.’ But what does she say to the next client, and in what emotional tone, when he reports how ‘I didn’t use mindfulness at all, I just couldn’t see the point’ or to a third client who says ‘I tried to use it but it just didn’t help me’. Therapists need to maintain balance in content and emotional tone of speech, without, of course, sounding monotone or robotic. Having two therapists helps with this.

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Use Positive Reinforcement One way to maintain balance is to be unfailingly accepting and reinforcing of clients. Operant conditioning and positive reinforcement are vital skills in a group. It is striking to read Yalom’s endorsement of this point: ‘Support the mute patient for staying the whole session; compliment the patient who leaves early for staying twenty minutes; support the patient who arrives late for having shown up; support inactive patients for having paid attention throughout the meeting. If statements are unintelligible or bizarre, nonetheless label them as attempts to communicate. If patients try to give advice, even inappropriate advice, reward them for their intentions to help’ (1995, p. 466). Yalom identifies psychotherapists’ own beliefs as the main obstacle to them using these vital behavioural skills: ‘Considerable research documents the efficacy of operant techniques in the shaping of group behaviour. Using these techniques deliberately, one can reduce silences or increase personal and group comments, expressions of hostility to the leader, or intermember acceptance. Though there is evidence that they owe much of their effectiveness to these principles, psychotherapists often eschew this evidence because of their unfounded fear that such a mechanistic view will undermine the essential human component of the therapy experience’ (p. 114).

Modelling A further behavioural skill that is familiar to cognitive therapists and very useful in groups is modelling. As Yalom (1995) states: ‘The leader always shapes the norms of the group and must be aware of this function. The leader cannot not influence norms’ (pp. 110–111). Therapists are always modelling interpersonal behaviour so it is important to model therapeutic interpersonal behaviour that embodies PBCT – respect, active listening, choice, reinforcement, collaboration, openness and participation. While transference to therapists of course occurs, I will usually not examine it directly, but prefer instead to continue to model these behaviours, seeking to engage with and encourage the person’s capacity to relate openly and collaboratively with others in this way.

Therapist Disclosure Therapist disclosure can be normalising, it can instil hope in clients, and dispel the illusion that the world is made up of people without problems and patients. In the mindfulness groups, for example, clients have reported how it is helpful to hear how therapists also have times of being lost in judgement, avoidance and rumination. But therapist disclosure is to be used sparingly in groups. It can appear to minimise the client’s difficulties.

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It can appear at a process level to be a clumsy attempt to ‘win clients over’. Clients might even wonder whether therapists’ own problems are sufficiently in hand to work with theirs. And remember that in groups you have several other people in the room, so the potential for people to misinterpret or feel concerned by your disclosure is greater than in one-to-one.

Agenda Setting in Action At the start of sessions some clients will put items on the agenda, but often little or nothing is offered. This is not a reflection on clients’ view either of therapists or groups. I am always prepared with a structure and sequence for the session, and some specific items for an agenda. I also allow for items to emerge, and respond by agenda setting in action. This readiness to ‘go with the flow’ and pick up important points as and when they arise is an important group skill, because many clients introduce important points in this way rather than as ‘up front’ agenda items. It is not aimless meandering because groups have clear structures and aims. Important points are likely to relate to one of the four domains of distress depicted in the ZoPD. If an important point does come up during a session, therapists can signpost this, stating why they think it might be worth spending some time on it, and checking if clients agree. This helps clients perceive flexibility as supporting rather than undermining structure and aims. As in individual therapy, therapists are responsible for managing progress through agreed agenda items that were set at the outset, so that these do not get missed.

Prevent Lengthy Silence Silence of more than a few minutes is likely to be unhelpful in groups for people with current distressing psychosis. Silence is a breeding ground for anxiety, voices, loss of purpose, paranoia and disconnection, and transference towards therapists. Basic counselling skills are essential for running groups – therapists can offer summaries, paraphrase discussion, and make links to goals. Therapists might equally feel it important to openly and collaboratively comment on the silences: ‘I notice we are having a lot of silence today. Have others noticed that? Is there anything about what we are covering today, or how you are feeling, that is making it more difficult to speak? What would make it easier to say things?’ Having said this, when asking a question it is important to allow time for people to answer if a group is to facilitate proximal development. This might even mean leaving a question for 30 seconds or so, and then asking it in a slightly different way if it still feels important. Anxious therapists often either jump in and supply an answer to their own question, or move on to a new topic and thereby miss an important opportunity.

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Explicitly Linking Current Work to Clients’ Goals Therapists through the use of flip charts, handouts, session summaries and specific prompts keep a link explicit between current work and clients’ goals. Clients are motivated to tolerate anxiety and difficulty, and expend effort, if they see how it is purposeful and bringing them closer to valued goals. It is important to hold in mind a person’s goals in terms of their ZoPD, and to offer regular reminders and links: ‘John, one of the things you hoped to get from being in this group was to find new ways of coping with voices, to feel less distressed by them. Has anything that has been said today linked with that?’

Supported Discovery in Groups Socratic dialogue is really effective in groups. The aim is to draw out what clients believe and experience, not to show what therapists believe and experience (see Chapter 2). PBCT groups are very much about making implicit meaning explicit. The following sequence illustrates this process with a client in a group who states ‘my voices rule my life’. (1) Therapists reflect that this feels a very important issue, one that threatens a central aim for clients in the group to learn to accept and live with voices. Therapists put this on the agenda ‘in action’ (see above), by checking if this is an issue for others in the group, and negotiating to spend some time on it: ‘Okay, so several of you have similar experience, and feel very distressed by this feeling of powerlessness. It links to important goals for the group, both in terms of understanding what makes voices so distressing and disabling, and in terms of learning to accept and live with voices. Shall we spend 10 minutes or so now looking at this in more detail?’ (2) Therapists draw out from different clients a range of emotions (Cs) and behaviour that go with this symptomatic belief (B). (3) Explore main evidence for the belief, always assuming people have good grounds for beliefs: ‘I’m sure you have really good reasons for saying that the voices control your lives. What kinds of things have happened?’ (4) Summarise main evidence for belief that voices totally control life. (5) Socratically begin to draw out counter-evidence by: • paradoxical injunction: ‘And no one has even had a different experience?’ or ‘And you do what the voices say all the time?’ or ‘So you are never able to resist voices?’ • direct questioning: ‘Has anyone ever had a different experience, one where you have not done what the voices said?’ • offering counter-evidence in a non-confrontational manner: ‘I’m remembering the fact that many of you have been commanded by voices

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not to attend this group, yet you did attend. How does that fit with the belief that voices are totally controlling?’ (6) Draw out evidence and summarise the degree to which people are not voice driven. (7) Summarise. Beware over-stating counter-experience. Reflect that voices have a considerable degree of control and influence: ‘So there are many times, such as when you are feeling low or stressed generally, when the voices are very dominant. That’s when it can feel like they have total control. But actually you all do have some personal and hard-won control’ – and offer short examples to back this up. Involving Group Members in Socratic Dialogue One advantage of groups is that other group members can provide here-andnow feedback (evidence) about key beliefs. In the following extract from a short-term group for people with distressing voices, Dianne expressed her feelings about having been admitted to hospital since the last session: D: The voices are telling me I’m a bad mum letting down my children being in hospital. T: What do you think, Dianne? D: They are right. I should be at home with them. They don’t understand why their mum goes into hospital. They cry when I go in. T: That sounds really upsetting for you all. Do you believe that you are a bad mum? D: Yes, I think the voices are right. T: Perhaps it’s worth you saying a little about what led to you coming into hospital. D: Well, the voices were getting bad. I just couldn’t cope with being at home. I was scared I might do something. T: Do something to the children? (Dianne’s biggest fear) D: Yes. I just couldn’t cope with them and voices. I asked my doctor to bring me in. T: So the voices are telling you that you are a bad mum for coming into hospital. Your own experience is telling you that once or twice a year things get so difficult at home that you fear you really might harm your children. At those times you ask to come in to hospital to protect your children. Which sounds to me like being a good mum. What do others think about this? (Gordon, who blames himself for being ill, joins in at this point.) G: You can’t blame yourself for coming into hospital. You don’t have a choice. You have to come in. At this point Diane smiles. The therapists use this change in affect to clarify again the link between feelings and beliefs. The therapists then turn

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to Gordon, and draw out how Gordon could be compassionate for others but not himself. T: Gordon, I remember that earlier today you were saying you felt you let your parents down badly by being ill. G: Yes, it upsets them. They don’t like to see me like this. T: How do you feel about this? G: Upset. I feel I’ve failed, really. T: You see it as in some way your fault. G: Yes. T: What do others think? Is it Gordon’s fault that he has voices and paranoia? Several people affirm strongly that it is not. What gives this added weight is that Gordon knows the people giving him this message understand the experience. T: What strikes me is that you all can be compassionate for others in the group, but not towards yourself. You blame yourselves for things like going into hospital, self-harm, hearing voices and not working, yet if others have the same experience you do not judge them, you support them. It sounds like you have been very effective in challenging each others’ negative judgements, and I wonder if this is something you could build on. Maybe it would help you at home if you are judging yourself to ask yourself, ‘How might Gordon or Dianne challenge the way I am judging myself?’ or maybe to ask yourself ‘If Gordon or Dianne were judging themselves in this way, would I agree with them or challenge their judgements. Would anyone be willing to see how this works and report back next time?’

Downward Arrow Across Individuals: Passing the Baton In groups it is very helpful to use downward arrow (thought chaining) to reveal important meaning across individuals, rather than completing a chain with one person. This is because completing a chain on one person could easily leave him feeling exposed and different. Also, it might discourage others from disclosing distress or key beliefs if they fear that they too will be ‘grilled’: ‘Well, if that’s what happens when you disclose something that is difficult, I don’t think I want to.’ There is a way of using the downward arrow method that supports group cohesion, which is to use a three-step cycle: (1) Make a little movement with one person. (2) Come back to the group and bring people together again around this new information.

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(3) Make a little more movement with a new person, and then move back to the group again, etc. For example, with paranoia, the following extract illustrates this process of using Socratic dialogue to gain a little movement, then going back to the group, then a little more movement. Jim: I went shopping with my mum. I felt terrible, really paranoid. I had to leave, I went home. T: That sounds like a difficult experience. You say you felt terrible, paranoid. What was going through your mind when you felt most distressed? Jim: Everyone looking at me. Talking about me. Sniggering. T: Right, so a powerful sense of being the focus of other people’s attention – that they were looking, sniggering. Is that an experience others have had? (Lots of nods and agreement) Jane: That’s what it’s like for me when I collect Jade from school. Everyone looking and talking, giving me dirty looks. T: So this seems important, what Jim and Jane are raising here. That maybe a key part of the experience of paranoia is feeling that others are focusing on you. And it sounds very much like the focus is negative; they are sniggering, giving dirty looks. Is that right? Don: Looking down on you. They see you as no good. They think they are better, just because they have smarter clothes they think they are better. T: Wendy, does any of this chime with your experience? Wendy: You can feel that they hate you, see you as nothing. It’s awful; you just want to get away as quickly as possible. T: So for you all, paranoia is a painful experience of being with other people. A sense that they are looking at you, talking about you, and a powerful sense of being judged as in some fundamental way being worthless, no good. Is that right?

Clarifying Understanding Just as in individual therapy, it is essential to clarify regularly understanding of a common concept, skill or insight. As well as offering a chance to work with any confusion, or misunderstanding, this also opens up one of the joys of running groups, which is to hear each person’s unique understanding. Initially people may feel they are being ‘tested’ and can feel self-conscious about getting it wrong. Unerring positive reinforcement and balanced replies from therapists usually ensure that this passes and the gains are considerable. Indeed, one of the merits of a group is precisely that clients can take risks with others in this way.

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Balancing an Individual’s Needs with those of the Group One of the arts of group therapy is to balance the needs of the individual with those of the group. If, for example, somebody discloses abuse, how should therapists respond? Well, of course, with empathy, with validation of the person’s courage, with understanding and with concern. Beyond this, it is crucial to maintain the balance of the group, and the sense of what the group is for. In effect, a vital therapist skill in time-limited structured groups is to know what not to investigate and explore. Keeping in mind the ZoPD helps guide this decision-making process. I recall one powerfully built man with paranoia saying at assessment that he would join a group, but only if he were free not to speak at all unless he wanted to. He literally did not speak a word for four weeks, until one of the therapists turned to him and asked him a question, at which point he stormed out, never to return. His silent presence had become such a dominant theme in the group, quite menacing for other clients, that the therapist behaviour was understandable. The error had been to agree at assessment to his demand to be allowed to remain silent because his need compromised that of the group.

Facilitating In-Group Relating One of the aims of any group is to encourage interpersonal relating and learning. For many clients there is a tendency to speak to and through therapists, and a key task for therapists is to support direct communication between clients. Therapists constantly make links between people: ‘John, that sounds a lot like what Jane said last week – that you each feel like a poor parent when the voices get at you.’ A step beyond this is to encourage clients themselves to build the bridges: ‘John, does what you’ve said remind you of what anyone else has said? In what way?’ or ‘Does anyone else know what John is saying here, does anyone recognise that feeling?’ Therapists seek opportunities for members to show one another concern, acceptance, understanding and respect – and underscore these whenever they occur. Universality also supports an interpersonal focus, and we repeatedly emphasise common humanity between members.

Responding to Challenges First, and foremost, when things feel like they are going wrong, redouble your commitment to the principles of radical collaboration and Rogerian acceptance. Interpersonal challenges occur when the group culture is placed in jeopardy by a person’s interpersonal behaviour. Try to note any urge to take control and mend things. Remain open, accepting any uncertainty you feel, and trust in the capacity of the clients to collaborate with

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you, and to preserve the group culture. I remember in the sexual abuse group mentioned above how on the first day when the female co-therapist was on a planned absence, no fewer than six members walked out of the group – first four left, then two more. What remains most memorable today is the way the three who remained preserved the group norms, made little or no comment on the departures, and used the time remaining productively. Challenges often occur because someone has broken the group norms, and this needs addressing. This occurred in a group for people with paranoia. Ron had a history of being sexually abused, long-standing paranoia and extreme social isolation. He could be very dismissive of others. On one occasion a client, Viv, described how one of the effects of paranoia had been for her to lose her religious faith, which had been a pivot in her life. Ron said, ‘That’s a load of bollocks, religion. I think it’s just a load of bollocks. I don’t believe in anything like that.’ The comment was addressed to the therapist. It was not intended as an attack on the person who had spoken, but inevitably was experienced as such. There were three issues I worked to achieve. First was to seek to connect with Ron, at a time of potential serious disconnection from the group, and avoid any sense of judging, or telling off, Ron. Second was to reaffirm the group norms of freedom to hold different opinions, and of accepting differences respectfully. I drew out how Ron was adhering to the first norm, and had not intended to show disrespect (i.e. any breach of the second norm was unintentional). I explored with Viv how she would have preferred Ron to express himself, and with Ron how he liked people to express disagreements with him. Thus the process became one of seeking to collectively reaffirm the norm that had been threatened. Third, we sought to promote group cohesion, especially between Ron and the group members, who recognised his distress and struggle in life, but needed some movement from him towards group norms.

SUMMARY PBCT groups adhere to all those principles described in the preceding chapters. What they offer in addition is a dynamic social process within which clients can work to achieve proximal development in all four domains of the ZoPD. This is a powerful vehicle for proximal development, which is always a collaborative social process. For therapists, the principles of radical collaboration still apply, and group aims and structure can be shaped collaboratively with clients to reflect specific needs and wishes, and to ensure that proximal development begins where clients are currently. An emphasis on therapeutic factors adds to understanding of the relationships within a group, and to the aims of group participation.

Chapter 9

ENDING AND THE PROCESS OF CHANGE

OVERVIEW This final chapter opens with consideration of the ending of therapy. Within PBCT, ending is an important process; relationship building is central to the approach, so loss of the relationship needs processing for clients and therapists. A grief and loss model is used, which identifies four distinct aspects to the process of ending. Client suicide, the most traumatic of all endings, is discussed. An overview of a typical course of PBCT is described, which involves a therapeutic and supportive phase. Lastly, the process of change is illustrated. This is done initially through one client’s writings of her experience of PBCT – this illustrates what relationship building and proximal development in the four domains actually feels like for clients. Finally there is an analysis of common psychological processes of change that cut across the domains of the ZoPD.

THE PROCESS OF ENDING Ending can refer to either a life event or a psychological process. Ending as a life event can be a one-off (an A within the ABC framework); ending as a psychological process refers to a changing cognitive/emotional response (B and C). Ending as a process is a dynamic, creative part of therapy, and a further time for open, collaborative working. What is being lost when therapy ends? Within a person model the emphasis is on the ending of a relationship, and the more therapist and client have been able to connect as two people, the more important this becomes. Whose ending is it? The emphasis is understandably placed on clients. But the ending of a relationship is very much for therapists too. This point is not negated by the fact that therapists have many clients, and clients usually but one therapist. It is helpful to conceptualise ending for clients and therapists in terms of an understanding of loss and grief. Some clients will be less affected by ending, and therapists’ feelings for clients will

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vary considerably, yet it remains important to process the loss – otherwise after therapy has ended ‘unfinished business’ can arise for both people. Worden (1983) identifies four main processes (not sequential stages) for responding to loss. (1) (2) (3) (4)

Accept the reality of the loss or ending. Experience the range of emotions. Adjust to an environment in which the person is missing. Emotionally relocate and move on in life.

Each process has its opposite. Denial of loss is the opposite of acceptance. Blocking, avoiding or suppressing feelings is the opposite of emotional processing. Persisting with old patterns is the opposite of adjustment to an environment without the other person. Ruminating on what has been lost is the opposite of emotionally investing energy in new relationships, and moving on. It is striking how these processes parallel those already discussed in this book. It involves turning towards painful feelings and allowing their emotional expression free from judgement or control. It is about being willing to let go of established patterns of thought and action, and openness to new experience and ways of living. It can help therapists and their clients to reflect together on an ending they feel positive about from their lives, and an unsatisfactory ending, and what made each what it was.

ENDING LETTERS One effective way of helping clients and therapists work through ending is for therapists to write an end of therapy letter. Clients are also invited to write a letter, though as with formulation letters, they often choose not to. For therapists a letter is also an opportunity to summarise a client’s proximal development in the four domains, to reinforce key messages, and offer guidance on managing setbacks. Ending letters are grounded in radical collaboration. This means that there was no outcome that therapy ought to have achieved. This framework of acceptance facilitates a positive and encouraging tone. Ending letters are a final opportunity to model Rogerian acceptance of all aspects of a person and therapeutic process. As in all PBCT, in ending letters it is crucial to avoid interpreting clients’ experience, being negative or judgmental, or pushing a personal agenda. It is surprising how easily resentments or frustrations lead therapists to want to use an ending letter to reaffirm their own views, or hint at a client’s intransigence. An ending letter is also not the time for big new ideas – there should be no surprises. Also, ending letters can all too easily become outcome focused. Letters begin focusing on the process of therapy, and how that has value in its own right, whatever the outcome. Rather than simply saying that they will miss clients, therapists identify

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attributes and qualities that will be missed (e.g. humour, creativity). If there were difficulties within the relationship therapists would find a positive way of referring to them. Letters summarise progress and key achievements in all four domains of the ZoPD, and ideas about how to continue this development. Letters clarify practical issues of how to access us again (we allow all our clients to contact us direct if they need future support). We would list specific steps for accepting and managing difficulties and setbacks.

Suicide For therapists, not to mention families and carers, the most traumatic ending is undoubtedly the suicide of a client. With the significant majority of clients with distressing psychosis with whom I have worked over the years, suicide has been a real risk. Risk assessment is ever present in therapy for people with distressing psychosis. Client suicide has thankfully been a rare event, but it does happen. It is always a shock to learn that a client with whom one is working, or has worked in the past, has committed suicide. There are strong feelings of sadness and loss of the client as a valued and unique person. There is compassion and sympathy for the bereaved family, friends and carers. There are often anxious self-concerns about practicalities; for example, are notes up to date? Over and above this, I have found suicide to be a last, powerful challenge to radical collaboration and acceptance. Surely, the implicit thinking runs, there is one should in therapy – we should be able to stop clients killing themselves. All the work described in this book is intended to help clients develop in ways that make their lives more meaningful, peaceful, enjoyable and fulfilling, and make suicide less likely. This is what I want deeply for all clients with whom I work. But fundamentally cognitive therapists cannot stop a client from committing suicide, and I believe it makes us less effective if we believe that we can and should be able to do this. Suicide is the most profound challenge to acceptance. At these times it would be superhuman not to doubt yourself, or the way you work. It is commonplace to have moments of thinking that you or the therapeutic approach failed the client and the family. It is difficult to hold on to how you as a therapist and person did your best to help the client, and to be open to the deeply painful and disappointing reality that this did not prevent the suicide. It is difficult to experience emotionally that a client’s death is a tragedy, not a failure – yet if experienced in this way, a client’s suicide increases motivation and commitment to continue seeking ways of helping clients free themselves from distressing psychosis. Therapists need regular supervision and might need additional support for some time following a client’s suicide. There is an increased

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likelihood therapists will feel anxious and be more prone to anticollaborative modes with clients (see Chapter 2). I recall vividly when two clients I had known committed suicide within three months of one another (the only occasion when this has happened). One was working with a therapist under my supervision, and one had attended a group I had run some months before. For several weeks after these deaths, when a colleague asked to speak to me I would often have an anxious automatic thought that another person had committed suicide. It is about being aware of these reactions and accepting them – they are a sign that you are human rather than weak. It is also about balancing these losses against the far more numerous positive, validating experiences. It was heart warming recently to have a client come over to me in a supermarket to say ‘hello’ looking well and happy. This man had been so suicidal that he had been an inpatient for three years continuously. I had worked with him for one hour a week for two years; nursing staff on the ward had provided 24 hours a day care for three years. There were many times when we had all struggled to retain a sense of optimism and confidence in his capacity for proximal development. It is about ensuring that positive experiences are fully experienced emotionally at the time, and finding ways of keeping them in mind (e.g. a memento or letter from a client on the office desk).

THE PROCESS OF PROXIMAL DEVELOPMENT: A CLIENT’S PERSPECTIVE PBCT is a therapeutic process of building a collaborative, accepting relationship and discovering what proximal development is then possible in the four domains of symptomatic meaning, relationship, schemata and symbolic self. Proximal development is the work of therapy. It begins where a client is. It is a process of collaborative exploration of a client’s potential development, free from anti-collaborative assumptions about how therapy should progress. A therapist cannot formulate a zone of proximal development in advance. Therapists formulate (see Chapter 3) where a client is now, in relation to the four sources of distress and what is known about a client’s positive strengths, attributes, social support, etc. But it is only through a collaborative process that a client’s potential for proximal development becomes apparent, or known. In this section, one client presents her experience of proximal development. In her own words, Val describes what it feels like to form a radically collaborative therapeutic relationship and to use this to realise her proximal development in each of the four domains. Her writings are presented together, in the order in which they were written over the course of 18 months of therapy, to convey this process.

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Writing Writing these notes over the therapy has sometimes been very upsetting for me. Seeing my experiences in black and white is quite disturbing. When I write, the voices often shout at me: ‘Stop writing, stupid cow’, ‘Fat ugly cow’, ‘No one’s interested’, ‘Cut yourself, cut yourself, you know you should, you know you should’ over and over. This happens anyway. I’ve often wanted to cut but have resisted this. When Paul and I were discussing what I want to achieve from doing this writing, very strongly, and for the first time, I said that what I had to say was important. When I realised what I had said I was taken aback. But maybe just maybe it’s true. God, this thought was very confusing as it sets off all sorts of voices inside and outside of my head. They are saying things I want to say cannot be important – I’m too stupid. What do I hope to get from this writing? I often think that I am misunderstood – there goes that mad woman – getting words muddled, stammering, talking crap. I’d like people to understand my background and how it has affected the person I am today. Now I feel it is time people need to know what I think. I want people to see me as an autonomous person, not as a mad woman. I hope what I’ve written is adequate. I hope I have been clear and maybe useful to those who read this. There is loads more I could write and maybe later will.

My Background Inevitably my voices come into my life history. Voices? What voices? Are you mad? Mad people hear voices not me. But what about Katie? Katie was the first (voice) – she was good – a comfort. She loved me. She was a bit, deep inside, which no one could attack. I was safe with Katie. Didn’t everyone have voices? I thought everyone had a safe place to go. I didn’t speak of her. It didn’t occur to me to speak about her. I went to her when things seemed dark – when things were dark! She was a little girl with blond bunches and pink cheeks. She would play with me. She was okay to have around. My little sister had imaginary friends that would walk, or swim, about the house, and she cried if anyone stepped on them. I didn’t know if Katie was the same as imaginary friends, or a real being. She would whisper to me if I did something wrong or if I did it right. I could check things out with her. But then, after a while, she stopped being safe, being fun, she started to shout at me. She became a torment. BUT she wasn’t a torment all of the time, she was still my oldest friend, so I kept, keep, hold of her! Katie was soon joined by others – other voices. There was nothing good about them. They constantly bashed, and bash, me on the head. The adult voices are a punishing, scary entity that have taken over my life. Now the voices are

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not one, they are many. The voices, now mainly male, have a powerful impact on my life. They are usually there all of my waking hours. Before I speak I have to check out what I’m going to say with the voices. Most of the time they say I’m talking rubbish so I have to choose something else – which usually is not right either. Now (as I write) the voices come thick and fast, constant, punishing. Sometimes, often, my mother talks for me, so the voices tell me to kill my own mother. Fairly early on I realised there was a secret past, secret events about me. I was different – sullied, guilty. When I was young a relative started sexually abusing me. It started as an innocent act of morning cuddles, until I accidentally called him ‘Daddy’. My father died when I was a baby. He got very angry – so angry I cried. His anger was terrifying. He touched me internally and said that I knew why. We shared the knowledge, fact that my father’s death was my fault and the abuse was my punishment. It was about this time, I think, that Katie started to hate me, and other voices appeared. He said if I told of what was going on my mother would hate me, that she would think I was dirty – reinforcing what I already believed about myself. I was, and still am, terrified of her rejection. The closest relationship (except with my mother) is (was) with my little sister. She is not really little, she is only a year younger than me and now has children of her own. Most of school life I felt ‘out of it’, feeling isolated. They made me see a psychologist who asked me inane questions and told me to make patterns out of coloured bricks. Needless to say this did no good. I didn’t tell him about the voices. The voices took up much of my time. If in school I wasn’t being disruptive, I was being withdrawn, listening to my voices. When I was about 14 I started cutting – the voices told me to, so to appease them I did. At first it was just scratches but it got worse. The sight of the blood was somehow satisfying. Sometimes I was trying to cut out the bad bits, to punish myself, the relief came but became hard and harder to satisfy. In these years I made a couple of ‘friends’, we became vandals, destroying property and getting drunk a lot. One of my friends had parents who were divorced. We met her father in a pub and inevitably got drunk. I went back to his flat where he gave me more vodka and we fucked. Fucked is the right word because we did not make love, it was just sordid, with him making repeated requests that I didn’t tell anyone. We carried on this ‘affair’ until one night we had been at a pub and he dragged me into a playing field and raped me. When he had finished with me he just got up and smiled, and walked me, still gripping me, home. I thought my mother might be able to see what happened. Part of me wanted her to know, but the other part thought she would blame me and see how dirty I had been again. All things seem to show is my history was all bad, well it wasn’t. Playing with my younger sister was often fun and special. We have still together very fond memories of our childhood, and the closeness sometimes still into adulthood. She moved apart when she went away to college. I stayed

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at home to study. Her college career was very successful and my study ended in disaster. I was alienated and isolated at college and my fears of others and failure became magnified. It all ended up at my ‘breakdown’ at the time of my first-year exams. I was sent to a psychiatrist and began my psychiatric ‘career’.

Beginning Therapy How I was when therapy began. I came to the present situation – seeing Paul after many years of ‘treatments’. At the time of starting this therapy I was an inmate in hospital. It was horrific. I think I was what they call a difficult patient. To be fair there were a couple of nurses who would take me seriously. In the early days of therapy they encouraged me, and without this encouragement I may not have carried on with the sessions. I was very confused and sometimes suicidal. I was feeling very desperate and self-harming regularly. Throughout this time I was battling with the voices. The voices were making me unable to do anything. The TV was talking to me. People were following me and they could see inside my head and read my thoughts. I was a bit sceptical of this ‘treatment’ but was desperate enough to try anything! Starting therapy with Paul was terrifying. I sat, avoiding eye contact, even avoiding looking up from the ground. Often I shook and often jumped at any unexpected sound. I was terrified. But it soon became clear he was not interested in my label. And it was also clear he was prepared to address the issue of my voices without belittling them or treating them as weird. The first session the voices were shouting and it was hard to concentrate. Paul recognised this and actually asked me what was going on with the voices. I didn’t feel at all ‘loony’. Paul made me feel that what I had to say was of some importance. Paul spoke – I needed him to speak and put me at my ease. Previously, I had seen a psychotherapist who waited for me to speak and often would not reply even when I had braved to utter a sound. The psychotherapist only spoke to throw back at me what I said. He gave me no idea of any directions that we would/might want to be going in. The collaborative relationship I have with Paul gives me confidence that my ideas, as well as his, are important. In this method I get to say what I want to work upon – I have some power in this relationship. Unlike the psychotherapist, Paul gives me feedback and some idea of his reaction and tells me what areas he might like us to cover. He does this while giving me a lot of power. I have been given other treatments. One of the most dangerous ‘treatments’ I have had has been the medical model. Ranging from low doses to massive doses of drugs and ECT. I have had different reactions. These have been as petty as a dry mouth, to slurred speech, to amenorrhoea, to lactation, to shaking, to memory loss, to damage to skin pigmentation, to

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very serious sight damage, to dizziness, to high blood pressure, all these and more. All these crap reactions and I ask for more drugs. I have, at times, put my faith in these drugs and am still waiting for the final ‘zonk out’ that I may get from these drugs. The numbness from these drugs is what I often seek – numbness is better than sharp reality. So I often say I want to be off medication, but part of me grasps the drug for fear of what it would be like without them.

Working with Voices Talking about the voices became open and ‘normal’. It has not been shied away from. We have looked at: where the voices came from, the effect they have on me, how I can let my thoughts and voices be [mindfulness], how voices feed on my present feelings, how I can, hopefully, partially control them. We have looked at coping strategies, some successful, some not so, and some just plain silly (humming while they are speaking: I could only think of Dionne Warwick songs!). One long-term strategy, the role-plays to challenging the voices, has proven to be, although the hardest, the most successful. As soon as a voice pops into my head I try to test out, with previous evidence, what the voice is saying. Whether or not it is even likely or true. They gave me a chance to look at things from the opposite side and to talk back to my voices. Tell them what I feel about them. It was good to see the other side to it always seeming true. Some of what the voices said didn’t make sense. It seems to me that the voices always feed off negative images I have about myself. I can think about the voices being a by-product of my own self-image. I’ve always thought myself as bad. Not just bad, but evil. I am evil. I do evil things and other evil things that appear to bear no relationship to me are my fault. I see some disaster on TV and it’s my fault. I believe that these voices are something apart from me, some evil entity that knows me and is punishing me. The voices often come up and interrupt sessions. We don’t just ignore them, we deal with them. We listen to what they say and see if it is related to what we are talking about (it nearly always is).

Am I Bad? At school they always called me bad because I played up and would not write. When they tried and could not get me to work they stopped calling me bad, and after sending me to a psychologist, called me mad (maybe they were later vindicated). At last, a psychologist who neither calls me mad or bad. Paul and I have talked about my feelings of bad as coming from my life experiences, not being intrinsically true. We have explored

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reasons for my poor self-image. Conversations about this I find very useful and have begun to challenge the life-long-held beliefs. If not bad then what? In writing this I can see changes in myself which is rather scary. If I’m not all bad, all stupid, all evil, then what am I? Today we tried, in part, to reconstruct myself. At the start of therapy I couldn’t even look at Paul let alone hold collaborative conversations with him. But today we are working together, not just talking about my negative but some good things about myself. We’ve identified some key areas where I’m not just crap at – I’m a drawer, a gardener, I’m reliable, I’m a reader, a writer, I’ve got a sense of humour. Sitting here just writing these aspects of myself, we have missed out important points – I’m a daughter, a sister, an auntie, a niece, a friend – and still a victim! But now I can, still seeing the negative, can see some positive – which I never could before. All of this is very frightening. I had been comfortable with Bad and Stupid. I know my ideas in different situations, I know how I would act and react, and how people would act and react to me. Now I have to make up a new set of rules/notes. I don’t know how to react to people what they would say to me. I have to change. There is still a lot of work to do from this point onwards, but I have made giant leaps and I am sure I can make more giant leaps forward.

CBT and More There is no magic wand. Progress for me has been bloody hard work. You can’t say ‘Goodbye’ to the voices, visions, or paranoia. But you can, through bloody hard work, be more in control of the issues you bring to therapy. To others it may not always seem to be working very well – there are times when I still hear voices, still get scared going on a bus, still have sleepless, troubled nights, still think people are untrustworthy. But, I am in more control. At last someone is listening to me. I do still hear voices, but I can fight back. I have learnt strategies to deal with them. I don’t get off the bus after one stop any more. I am spending shorter amounts of time being an inmate in hospital. People don’t always see these things when they look at me. They may say I haven’t changed but I know I have. I expected that this would be it – I would see a therapist who specialised in working with people who hear voices. But he had no quick answers. I was not after one session cured. I don’t think that we should be passive, waiting for the ‘magic wand’ (although it would be nice). But you should expect understanding, collaboration, outlets for your own creativity, and partnership. The collaborative way we work has given me some control and I’ve felt fully involved in the treatment. Don’t expect a magic wand, expect work.

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Ending Letter In conclusion … Therapy – Great! I can now get on buses; I can now look at people – not everyone who looks at me is going to kill me; not every white car is following me; not every shop keeper thinks I’m shoplifting; not everyone in a long coat is spying on me. There are many aspects of therapy, all new and exciting to me. Paul came to therapy with refreshing ideas – it seemed he was, from the outset, committed to therapy. His commitment was encouraging, this was very promising. He never pretended to have all the answers. He was never 100% sure. With voices, he offered no sure answers either, just acknowledging that voices existed to me in whatever form. Always before, health professionals had just said, ‘Voices, mad, give her some drugs, pop a pill’, that’s the answer. They never asked what the voices said, never asked me what I thought they are – they were just a symptom. Because Paul was so honest with me, I could be open and honest with him. I trusted him. I wasn’t afraid of his ridicule or rejection. He never pretended there was any magic wand, just hard work. Voices don’t control me any more. They’ve not gone, but are a part of me. I don’t think they will ever completely disappear. I think I know where they come from – I don’t believe they are just a physical phenomenon, but I think originate from my early experiences. They are most apparent when I am under stress, or having a bad time, but they don’t run my actions any more. I realise I have options. I can choose whether or not to act on what they say, whether to listen to them or, sometimes, to put them aside for a while and come back to them when I’m more able to deal with them. Voices can be lived with. I can choose to be dominated by the voices, who stay the same year in year out, or I can work hard to lessen their impact on my life. Because of the collaborative (a very important word) alliance Paul and I built up, we were able to approach the problems I have in a positive and open way. We worked out questions and ideas with both of us, actually talking honestly and exploring all aspects of my differing ideas about myself, others, and so-called imaginations. This therapy, for once, made me feel powerful, like I had some control over my treatment and my life! One of the main strings of my progress has exactly been this writing. I find writing about myself very therapeutic. I can sort things out in my head, then write them down and explore them (I’m probably very vain). I also hope that in writing about my experience as well as helping myself, I can help others. I come now to the end of my therapy with mixed feelings – what next?, where do I go from here (am I cured!)? I have ambitions like any one else, but I don’t know what. The writing makes me feel powerful, my woodworking gives me great satisfaction, often frustrations, but mainly great satisfaction.

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Now, having built a new image of myself, I have to build with other people a new image of myself. I’m sometimes nervous, sometimes agitated and, yes, I still sometimes hear voices, get paranoid, but I have different and important facets of myself. I can write, I can draw, I can paint. I can restore and decorate a piece of furniture. What I want more than anything is not to be underestimated. Thanks, Paul.

THE COURSE OF PBCT Typically when PBCT works through all four domains of the ZoPD, it lasts around 9–12 months of regular sessions – usually weekly, perhaps dropping to fortnightly after 8 months or so. The process can be achieved by moving between individual and group PBCT – for example, mindfulness is often introduced in groups. PBCT tends to progress in a natural sequence, though not rigidly so. The order of the chapters in this book reflects the sequence in which exploration of proximal development occurs across the four domains – symptomatic meaning, relationship, schemata and symbolic self. A representative process for PBCT would thus be: (1) Relationship building and radical collaboration. (2) Formulating current sources of distress plus positive strengths, attributes, etc. (3) Working with symptomatic meaning. (4) Mindfulness. (5) Working with NSS and rules. (6) Drawing out and consolidating PSS and rules. (7) Working with symbolic self (self-acceptance). (8) Supportive phase. (9) Ending. Once under way, exploration of each domain runs concurrently. A key challenge for the therapist is to use the concept of a ZoPD to retain a sense of purpose and conceptual clarity when working in these different domains (see Chapter 3). Typically after clients have explored proximal development in the four domains, there is a further period of around 6–12 months of less frequent meetings – perhaps once every 4–6 weeks. This latter supportive phase is to consolidate change, support clients through setbacks, and support them as they articulate and experience living according to the new values and rules they generate. One of the most rewarding aspects of PBCT is to experience a person with psychosis let go of habitual judgmental rules and assumptions about how he should live, and to develop and explore new values based in acceptance of self and others. At this stage, therapists are often in a Rogerian counselling mode, which is to come full circle back to the opening sessions of meeting the person, not the problem (Chapter 2).

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THE PROCESS OF CHANGE All the methods described in this book involve two linked properties – an experiential affective element, and a (cognitive) transformation of meaning. In keeping with a Vygotskian perspective, the two are part of a dialectical process. Moreover, this developmental process is fundamentally social. It occurs between client and therapist, as the two collaboratively explore the client’s potential to understand and ease the sources of distress in his life, and to create a more balanced, accepting and fluid sense of self. As the two-chair enactment of positive schematic experience shows, this process of change can be based in transformation through positive emotional experience allied to new meaning, not only negative. A radically collaborative therapeutic relationship is in itself both a positive emotional experience and a source of new meaning. Again, our research on mindfulness indicates that when clients learn to relate mindfully to unpleasant psychotic sensations, they gain metacognitive insight through both negative and positive emotional experience – they observe not only the distress of struggling against unpleasant sensations, but also experience the physical and emotional well-being that goes with an accepting, open awareness of the same sensations (Abba et al., 1996). Proximal development occurs as much through a dialectical relationship between positive emotional experience and new learning, as between distress and new learning. In more detail, there seem to be six distinct elements to the process of proximal development in PBCT. These are depicted in Figure 9.1. While the six are numbered and do occur in a natural sequence, once under way each is part of a social developmental process of proximal development.

1. Choice to engage in collaborative therapeutic process

6. Acceptance of self as changing, contradictory and complex process

5. Experiential awareness and embodiment of positive aspects of self

Figure 9.1

Process of change in PBCT

2. Decentred awareness of current distressing experience

3. Metacognitive insight into sources of distress and well-being

4. Acceptance of unpleasant experience as part of self

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Relationship Building The starting point for this dialectical process of change is relationship building. Clients experience and learn to trust in therapists’ capacity to meet them as people, rather than as diagnoses or problems. They experience therapists’ commitment to easing their distress and supporting their quality of life, rather than trying to get rid of their symptoms (voices, images, etc.). They experience a sense of autonomy that comes from therapists not trying to push them in preconceived directions, and from knowing that remaining in therapy is a choice. They experience how therapists remain accepting of their experience, of them as people, and of their choices and development. They choose to commit to a realistic relationship in which there are no quick and ready solutions to their distress, but rather a shared commitment to open collaborative exploration of proximal development. When it comes to the social aspect of proximal development, groupbased PBCT has an added dimension. Small social groups are a powerful source of anxiety for so many clients. As Yalom (1995) urges, interpersonal relating remains central to any group therapy. The methods of PBCT are used in groups to facilitate proximal development by making explicit the beliefs and metacognitive insights that are embedded in this emotionally charged relating. Again, this relating is also emotionally positive – for example, in being able to express altruism for others in the group, clients ‘live’ aspects of the self that support a PSS and challenge the global and stable quality of the NSS.

Decentred Awareness of Difficult and Painful Experience Proximal development requires a willingness to open awareness to difficult and painful cognitions and feelings. It is the opposite of experiential avoidance, and is instead a deliberate turning towards these experiences. Nor is it immersion in these experiences. Rogers (1961) calls this process ‘getting acquainted with each piece of the self’. To get acquainted with unpleasant psychotic sensations is to experience them clearly just as they are. This depends upon decentred awareness (Teasdale et al., 2002) in order to experience them free from the whirl of habitual reactions. The similarity in approach between Rogers and later mindfulness-based interventions is striking (Rogers openly acknowledges an ‘Eastern flavour’ in his approach). Rogers’ writings contain numerous statements that might appear today in a book describing mindfulness-based interventions. To give but one example, he states (1961, p. 80): ‘one of the fundamental directions taken by the process of therapy is the free experiencing of the actual sensory and visceral reactions of the organism without too much attempt to relate these experiences to the self. This is usually accompanied by the

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conviction that this experience does not belong to, and cannot be organised into, the self.’ Opening awareness to include the unpleasant gives therapy an emotional ‘lived’ quality (Greenberg et al., 1993), and is an essential source of the affective half of the cognitive–affective dialectical process of change. As befits a person-based approach, rather than a symptom-based one, deliberate exposure to painful experience goes well beyond awareness of unpleasant psychotic sensations. It occurs when clients explore trauma, when they encounter other painful experience during mindfulness practice, when they inhabit an NSS in a two-chair enactment, when they undertake BEs, as well as when they role-play with voices, etc. For people with psychosis these methods will all involve a degree of unpleasantness and even distress. In choosing to face distressing thoughts, voices, images or feared experiences, clients reclaim some of their power. There is a point at which for all people intensity of distress overwhelms capacity to cope and learn. This is why in PBCT turning towards the difficult always has a clear rationale and framework to support metacognitive insight, and includes strategies to manage distress (e.g. limiting the NSS to no more than five minutes in two-chair enactments).

Metacognitive Insight into Sources of Distress and Well-Being Having chosen to experience distress it is vital to learn from it. David Clarke’s (1989) research on panic disorder shows how distress and fear of calamity can persist in spite of literally thousands of false positives. In other words, distressing cognitive reactions (meaning or relationship based) appear not to habituate, at least for many clients. Our research showed how symptomatic beliefs are maintained because they regulate behaviour, attention and interpretation of experience (Chadwick & Lowe, 1994). A key process of change in all four domains is gaining metacognitive insight into sources of distress and well-being. With symptomatic meaning, for example, this means to make explicit through ABC assessment a person’s symptomatic beliefs and show how they drive distress and behavioural disturbance. So long as distressing cognitive reactions to psychosis remain fossilised (Vygotsky, 1978), and thus outside awareness, then clients will remain trapped by them. Clients need to decentre from these reactions and develop metacognitive insight about them – the ways they regulate behaviour and cognition, their emotional impact and social cost, etc. Because reactions, unlike sensations, are effortful, the reaction ceases in the moment a person decentres from it. I cannot in the same moment both be lost in judging myself and have decentred awareness that this is what I am doing – rather, I can decentre from the reaction, realise that I was lost in judgement, and notice what that felt like emotionally,

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psychologically and physically. This latter process is enshrined in mindfulness practice and in two-chair methods for taking a metacognitive perspective on NSS described in Chapters 6 and 7.

Accepting Psychosis Accepting psychosis, rather than trying to get rid of it, is not a new concept – in a landmark book, Romme and Escher (1994) advocated this stance in relation to voices. In the present context, what does it mean to accept psychosis? Accepting psychosis has two components, one relational and one meaning based. The relational component of acceptance is manifest in moments when unpleasant psychotic sensations occur. It is a willingness to let go of fighting against the experience, or trying to get rid of it, and instead allowing voices, thoughts and images to come into awareness and pass without judgement or struggle. This is an intentional relational act, not a belief. The other element of acceptance is the metacognitive insight that these experiences are a part of the self. This insight occurs when a client says ‘I know that my voices will not go, but that’s okay, they are a part of me’. It occurred when Val (Chapter 6) retained half the pieces of paper representing her NSS, saying it is a part of me, just not all of me. In PBCT it is thus important to accept psychosis as a part of the self, but not something that can ever define the self. It is important to distinguish this from a common stance in mindfulness-based therapies to assert of a specific cognition, ‘this is not me, not mine’. Within Buddhist psychology, this statement reflects not only transience of all sensations, it also reflects a view that there is no fixed shelf to possess thoughts, and understanding that all sensations are conditioned by an infinitely complex matrix of prior and current events. In PBCT it is helpful to view a sensation as ‘not me’ (i.e. not defining the self). Yet outside a Buddhist context, urging clients to view thoughts, images or voices as ‘not mine’ can be confusing (they might reasonably ask ‘whose is it?’) or even interpret as not accepting the thought or voice. In PBCT it is more helpful to explicitly accept unpleasant psychotic sensations as part of a fluid, complex self: one is, in effect, saying ‘this experience is a part of my changing self, and I can accept it as such’.

Getting Acquainted with Positive Aspects of Self A key element in the process of PBCT is getting acquainted with positive aspects of the self. Again, this is a cognitive and affective process. All too often, positive experience is at best half experienced, because of interruption by inner critics (Greenberg et al., 1993) and voices, or because of divided awareness.

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The therapeutic relationship is a fertile source of positive experience. Therapists are alert for emotionally charged moments of connection, compassion and acceptance, and at these times help clients to make the implicit personal and interpersonal meaning explicit, and to then accept these feelings and attitudes as parts of the self. Imagine a therapist who makes a mistake over the timing of an appointment, and apologises. If a client accepts this, why does this happen? What is the implicit social rule that leads the client to forgive the therapist’s mistake? This positive accepting rule can be drawn out and set alongside any negative schematic rule the client holds (and most likely applies endlessly to himself): ‘Okay, John, so we’ve seen that you have two ways of relating to mistakes. You can be very harsh and unforgiving, when you follow the rule ‘‘To be acceptable I must never get things wrong’’. You can also be generous and forgiving towards me, when you follow the rule ‘‘If people try their best, mistakes will happen’’. You have both these attitudes and feelings within you. I wonder if you could begin to apply the second rule to yourself a little, what might that be like?’ Positive experience is not ‘puffed up’ (Chapter 7), but realistic and grounded in ‘emotionally lived’ experience (Greenberg et al., 1993). A key part of this process is encouraging clients to articulate, often for the first time, positive rules by which to live, and the personal and social wants and needs that flow from them. Decentring from the interpersonal rules of the NSS creates a creative vacuum. In these moments clients are invited to make explicit deep-seated personal rules, which often have a humanistic or even spiritual flavour, and crucially to apply these to themselves. So many clients are intuitively compassionate and accepting towards others, but not towards themselves. This intuitive compassion and acceptance of others flows from implicit standards and rules about how to live. These rules need to be brought to the fore, as they connect to the important Rogerian assumption that people’s core is a potentiality under the right environmental conditions to become oneself as fully as possible in a positive and social way. Therapists explicitly encourage clients to articulate how these new rules would lead them to behave interpersonally (as in the two-chair transcript, Chapter 7) and to pursue life goals in ways that flow from these new positive rules.

Self-Acceptance: ‘I’m Fine Whatever Happens …’ A final key aspect of PBCT is self-acceptance, expressed through the symbolic self. The symbolic self is an expression of the metacognitive insight that there can be no fixed negative self. Symbolic self is a metacognitive insight into how ‘self’ is a changing process of vivid, complex and contradictory sensations, reactions, cognitions, emotions and behaviours. This insight replaces a fixed, narrow and distressing sense of self. It means

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even deeply painful and disturbing psychotic experience can never define the self. This is the essence of Rogerian self-acceptance: ‘The end point of this process is that the client discovers that he can be his experience, with all of its variety and surface contradiction: that he can formulate himself out of his experience, instead of trying to impose a formulation of self upon his experience, denying to awareness those elements which do not fit’ (Rogers, 1961, p. 80). Clients sense how their worth does not depend on getting rid of psychosis or never again reacting to it, or never failing at a task, nor being rejected. This was expressed powerfully by Robin’s (Chapter 6) new rule, ‘I’m fine whatever happens …’

CONCLUSION In summary PBCT is an approach to understanding and alleviating distress and disturbed behaviour. The focus throughout this book has been on psychosis, yet the four domains of proximal development apply in many if not all clinical problems, and I and colleagues have begun to use it more widely. It integrates cognitive theory and therapy, mindfulness, Rogerian principles, and a Vygotskian social–developmental perspective on the process of change. It is the culmination of a decade spent developing a person-based approach to distress that places the person at the heart of the therapeutic process, rather than symptoms.

Appendix

BAVQ–R

There are many people who hear voices. It would help us to find out how you are feeling about your voices by completing this questionnaire. Please read each statement and tick the box which best describes the way you have been feeling in the past week. If you hear more than one voice, please complete the form for the voice which is dominant. Thank you for your help. Name: Age:

......................... .........................

Agree Agree Disagree Unsure slightly strongly 1 My voice is punishing me for something I have done 2 My voice wants to help me 3 My voice is very powerful 4 My voice is persecuting me for no good reason 5 My voice wants to protect me 6 My voice seems to know everything about me 7 My voice is evil 8 My voice is helping to keep me sane 9 My voice makes me do things I really don’t want to do

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Agree Agree Disagree Unsure slightly strongly 10 My voice wants to harm me 11 My voice is helping me to develop my special powers or abilities 12 I cannot control my voices 13 My voice wants me to do bad things 14 My voice is helping me to achieve my goal in life 15 My voice will harm or kill me if I disobey or resist it 16 My voice is trying to corrupt or destroy me 17 I am grateful for my voice 18 My voice rules my life 19 My voice reassures me 20 My voice frightens me 21 My voice makes me happy 22 My voice makes me feel down 23 My voice makes me feel angry 24 My voice makes me feel calm 25 My voice makes me feel anxious 26 My voice makes me feel confident

When I hear my voice, usually … Agree Agree Disagree Unsure slightly strongly 27 I tell it to leave me alone 28 I try to take my mind off it

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Agree Agree Disagree Unsure slightly strongly 29 I try to stop it 30 I do things to prevent it talking 31 I am reluctant to obey it 32 I listen to it because I want to 33 I willingly follow what my voice tells me to do 34 I have done things to start to get in contact with my voice 35 I seek the advice of my voice

Scoring Guidelines All items have a four-point response range, Disagree (score 0), Unsure (score 1), Agree slightly (score 2) and Agree strongly (score 3). The questionnaire has three scales measuring meaning given to the voice: Malevolence (items 1, 4, 7, 10, 13, 16) Benevolence (items 2, 5, 8, 11, 14, 17) Omnipotence (items 3, 6, 9, 12, 15, 18) These three scales therefore have a range of possible scores 0–18. Following the original BAVQ, the questionnaire also measures Resistance and Engagement, two ways of relating to voices. Resistance and Engagement both contain emotional and behavioural items. Resistance • Emotion (items 20, 22, 23, 25): range 0–12 • Behaviour (items 27, 28, 29, 30, 31): range 0–15 Engagement • Emotion (items 19, 21, 24, 26): range 0–12 • Behaviour (items 32, 33, 34, 35): range 0–12 Emotion and behaviour scores can either be totalled to give one overall score for Resistance (range 0–27) and Engagement (range 0–24), or looked at separately, or both.

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INDEX

ABC framework 1, 3, 45–50 assessment of symptomatic meaning 59–62 formulation of distressing voices 46–8 formulation of paranoia 48–50 formulation of symptomatic meaning 45–50 model of distress 13 abuse transcript 107–9 two-chair methods 107–9 acceptance properties 89 of PSS and NSS 129–31 Acceptance and Commitment Therapy (ACT) 11 acceptance of psychosis and self 7–9, 89–90, 171 self-acceptance 90 supported discovery 89–90 active listening 27, 31–2 agenda setting in action, groups 150 aims, groups 144 alternative symptomatic meaning 63–5 transcript 64 anti-collaborative modes 21–3 challenge 26–7 assessment and selection, groups 142–6 associative listening 27 attention drain 95

Beckian developmental diagrams 54–6

groups 55–6 behavioural experiments (BEs) 71–3, 100–1 form 74 sequence 72–3 Beliefs About Voices Questionnaire - Revised (BAVQR) 47–8, 174–6 Bentall, Richard 1 Boyle, Mary 1

case formulation materials 39–40 category mistake 14–15 CBT anti-collaborative modes 22 characteristics 20–1 change process 168–73 acceptance of psychosis 171 decentred awareness of difficult experience 169–70 metacognitive insight 170–1 positive aspects of self 171–2 relationship building 169 self-acceptance 172–3 choice 71 choiceless attention 96 client 33–4 anxiety 144 beliefs 25 letters 44–5 psychotic experience 34 cognitive mediational model of distress 3 ABC model 3 cognitive model sharing 68–70 derogatory voices 68–70 Unicorn method 68–70

184

INDEX

cognitive therapy for delusions, voices, paranoia 1–6 symptom-based approach 1 therapeutic relationship 5 therapy as conceptual process 6 collaboration see radical collaboration common language 29–30 conditional rule 113–14 content see symptomatic meaning continuity 2 Crap or Perfect ruler 114 Critic 104, 116, 121, 129 CT and metacognitive insight 90–2 and mindfulness 12–13 Socratic dialogue 92

decentred awareness 18, 78–88, 94–5 and metacognitive insight 18, 78–80 of difficult experience 169–70 delusions, schemata and distress 3–4 Dialectical Behaviour Therapy 11 disclosure, groups 143–4 distress 2–3, 7, 29–30, 50–1, 170–1 cognitive model sharing 68–70 formulation 45–50 and mindfulness 12 see also mindfulness doubt exploration 62–3 seven-point sequence 63 downward arrow 4, 60, 153–4 transcript 153–4

Ellis, A. ABC framework 3 Rational Emotive Behaviour Therapy (REBT) 3, 93 shame attacking 100 empathy 27–9

ending 157–73 change process 168–73 ending letters 158–60 PBCT course 167 process 157–8 proximal development: client 160–7 ending letters 158–60, 166–7 suicide 159–60 engagement 7 evidence see goodness of fit experiential methods of change 99–100 eye of storm 96

fear 48–9 feeling tone 46 fixity 73–4 formulation letters 40–5 client letters 44–5 content 40–1 therapist letters 41–4 fossilised behaviour 15, 93, 104, 170

Garety, Philippa 1 good enough understanding 27–9 transcript 28–9 goodness of fit (evidence) 62–3 balanced summary 63 doubt exploration 62–3 groups see PBCT groups

hallucinations 46–8

ideas sharing 31–2 Insight Meditation 12 interpersonal assumptions 112–15 conditional rule 113–14 Crap or Perfect ruler 114 metacognitive insight 113

INDEX

positive rule 114–15 rules 112 supported discovery 113, 115 interpersonal relationship with voices 66–7

judgement 12 judging behaviour 93

Kant, I. 5, 32 kindness to self 84–5

letting go of reactions 86–7 longitudinal diagram see Beckian developmental diagram

magic if method 115 markers for PSS 119–21 meaning and relationship link 13–14 metacognition 7, 17–19 decentred awareness 18, 78–80 letting go of reactions 86–7 in PBCT 19 two-chair methods 104–7 metacognitive alternative 65–6 metacognitive insight 113, 170–1 interpersonal assumptions 113 Socratic dialogue 92 transcript 91–2 use of CT skills 90–2 mindful awareness 82–5 choiceless awareness 84 kindness to self 84–5 noting voices 85 mindfulness 7, 11–14 attention drain 95 choiceless attention 96 constant voices 95 and CT 12–13 decentred awareness 94–5

185

distress 50–1 eye of storm 96 feeling tone 46 fossilised behaviour 93 Insight Meditation 12 issues and challenges 92–6 judging behaviour 93 meaning and relationship link 13–14 not being drawn into meaning 92–3 practice 94 for psychosis 81–2 and schemata 100 see also relationship: mindfulness practice Mindfulness Based Cognitive Therapy (MBCT) 11 Mindfulness Based Stress Reduction (MBSR) 11 mindfulness rationale 80–1 Socratic dialogue 81 modelling, groups 149

negative automatic thoughts (NATs) 23, 31 negative other schemata (NOS) 98, 115–16 negative self schemata (NSS) 6, 15–16, 52–4, 98–9, 121–5 acceptance 129–31 Critic 104 Socratic dialogue 121–2 therapy transcript 104–7, 122–5

openness 32–3 letters 32 paranoia ABC formulation 48–50 fear 48–9 schematic paranoia 49–50 symptomatic paranoia 49 therapist incorporation 75–7

186

INDEX

PBCT groups agenda setting in action 150 assessment and selection 142–6 balanced stance 148 challenges 155–6 clarification 154 client anxiety 144 developmental diagrams 55–6 disclosure 143–4 downward arrow 153–4 expectations and aims 144 getting started 146–8 group design 140–2 in-group relating 155 individual needs 155 involvement 147–8 link work and goals 151 modelling 149 people not problems 148 positive reinforcement 149 process and structure 141–2 rules and norms 145–6 silence 150 Socratic dialogue 151–3 supported discovery 151–3 therapeutic factors 138–40 therapist disclosure 149–50 therapist role 145 see also person-based cognitive therapy person-based approach to psychosis 6–7 person model 6–7 person-based cognitive therapy (PBCT) 7–19 case formulation materials 39–40 change process 168–73 course 167 metacognition 17–19 mindfulness 11–14 self in PBCT 14–16 therapeutic relationship: radical collaboration 7–9

Zone of Proximal Development (ZoPD) 9–11 see also PBCT groups positive reinforcement, groups 149 positive rule 114–15 positive self schemata (PSS) 15–16, 52–4, 98, 111–12, 125–9 acceptance 129–31 maintenance and generalisation 111–12 markers 119–21 Rogerian positive energy 112 therapy transcript 126–9 proximal development: client 160–7 am I bad? 164–5 background 161–3 beginning therapy 163–4 CBT and more 165 ending letter 166–7 working with voices 164 writing 160–1

radical collaboration 7–9, 20, 24–33 active vs associative listening 27 challenge anti-collaborative modes 26–7 common language 29–30 good enough understanding 27–9 ideas sharing 31–2 openness 32–3 positive assumptions 33–6 supported (guided) discovery 30–1 relationship: mindfulness practice 78–97 acceptance of psychosis and self 89–90 decentred awareness and metacognitive insight 78–80

INDEX

letting go of reactions 86–7 mindful awareness 82–5 mindfulness issues and challenges 92–6 mindfulness for psychosis 81–2 mindfulness rationale 80–1 turning towards the difficult 87–9 relationship 10–11, 37, 50–1 distress formulation 50–1 relationship building 20–5, 169 anti-collaborative modes 21–3 client beliefs 25 meet person not problem 23–5 Rogers, C. 8–9, 75 acceptance 148 Rogerian positive energy 112 self-acceptance 16 role-plays process 101–2 Socratic dialogue 101–2 rules see interpersonal assumptions rules, groups 145–6

schemata 10–11, 37, 98–116 experiential methods of change 99–100 interpersonal assumptions 112–15 and mindfulness 100 negative other schemata (NOS) 98, 115–16 negative self schemata (NSS) 52–4, 98–9 positive self schemata (PSS) 52–4, 98, 111–12 two-chair methods and NSS 103–10 working with NSS 98–9 schematic meaning 58–9 self, positive aspects 171–2 self-acceptance 16, 89–90, 103, 172–3

187

self-acceptance and symbolic self 117–37 acceptance of PSS and NSS 129–31 client analysis of two-chair method 134–6 experience of self 118 negative self schemata (NSS) 121–5 new metacognitive symbolic self 131–6 positive self schemata (PSS) 125–9 two-chair method 118–21 use of two-chair method 136–7 shame attacking 100–1 silence, groups 150 Socratic dialogue 81, 92 groups 151–3 mindfulness rationale 81 NSS 121–2 role-plays 101–2 supported (guided) discovery 31 transcript 152–3 suicide 159–60 supported (guided) discovery 30–1, 79, 89–90, 103, 113, 115 groups 151–3 Socratic dialogue 31 symbolic self 10–11, 16, 37, 117–18 new metacognitive symbolic self 131–6 therapy transcript 132–6 see also self-acceptance and symbolic self symptom-based approach 1 ABC framework 1 symptomatic meaning 10–11, 37, 58–77 ABC assessment 59–62 ABC framework 45–50 ABC model of voices 46–8 alternative symptomatic meaning 63–5

188

INDEX

approaches 58–9 behavioural experiments (BEs) 71–3 choice 71 cognitive model sharing 68–70 fixity 73–4 goodness of fit (evidence) 62–3 interpersonal relationship with voices 66–7 metacognitive alternative 65–6 schematic meaning 58–9 sensations and meaning 61–2 therapist conviction 74–5 therapist incorporation into beliefs 75–7 transcript 61 usefulness: advantages and disadvantages 70–1

therapeutic relationship 5, 21–3 radical collaboration 7–9 therapist acceptance 8–9 assumptions 21–3, 33–6 conviction 74–5 group disclosure 149–50 incorporation into beliefs 75–7 interpersonal behaviour 35–6 PBCT group role 145 responsibility 34–5 therapy as conceptual process 6 understanding distress 35 ZoPD 39 thought chaining see downward arrow trust 75–6 turning towards the difficult 87–9 two-chair methods 104–7, 118–21, 136–7

and NSS 15–16, 103–10 abuse 107–9 client analysis 134–6 experience of self 109–10 markers for PSS 119–21 metacognitive perspective 104–7 process 119 self-acceptance 103 supported discovery 103 transcript 104–7

Unicorn method 68–70 usefulness: advantages and disadvantages 70–1

voices 164 ABC model 46–8 BAVQ-R 47–8, 174–6 client relationship 67 constant 95 derogatory 68–70 empty-chair technique 66–7 interpersonal relationship 66–7 mindful awareness 85 omnipotence 66–7 relationship now 67 see also ABC formulation Vygotsky, L. S. fossilised behaviour 15, 93, 104, 170 higher psychological functions 15

world of appearances 5 writing 160–1

Yalom, I. D. 138, 149 eight therapeutic factors 139

INDEX

group planning 140–2 group psychotherapy 138

Zone of Proximal Development (ZoPD) 9–11, 37–57 case formulation materials 39–40

189

client’s perspective 38–9 relationship 10–11, 37, 50–1 schemata 10–11, 37, 52–4 symbolic self 10–11, 37 symptomatic meaning 10–11, 37, 45–50 and therapy 39 as therapy guide 39

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