Clinical Handbook of Mindfulness (100 page)

of safeness and integrity to be used as a resource when coping with every-

day stressful events. Becoming aware of one’s emotions and sensations is also

identifying them as what they are (just feelings), not having to resort to alter-

native interpretations such as delusions, in order not to dissolve once again

into the inexplicable and the unspeakable.

After clinical stabilization, John willingly got involved in a CBT programme

for psychotic patients, which of course included some mindfulness sessions.

Because of his taste for physical activity, he showed particular interest in the

importance that was given to corporeity. Focusing on his breathing and body

through “body scan,” and on his body-environment interactions through

“mindful walking,” he slowly developed a new perception of himself and

the functioning of his body. Being aware of an underlying physical integrity,

despite any changes in his physical sensations, due to variations in his emo-

tional state, provided the patient with a new cognitive scheme allowing him

to go on with psychotherapy with more confidence and peace of mind
.

Some Practical Variations of the Protocol

Mindfulness-based strategies for treatment of psychotic patients have already

been implemented
(Chadwick, 2006; Garc`ıa Montes et al., 2004).

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Antonio Pinto

Chadwick highlights some examples of the use of a modified mindfulness

protocol, stressing in particular the effectiveness of mindfulness in coping

with the voices “
rather than getting rid of them
:

From the very outset I clarify that mindfulness will not get rid of voices,

thoughts, images, and so on. It involves practicing a different way of

responding to them. It is about learning to accept and live with these expe-

riences without feeling preoccupied, ruled, dominated and overwhelmed

by them
”
(Chadwick, 2006).

We fully share his adjustments to the standard protocol as necessary to

adapt it to the specific characteristics of this kind of patient.

They indeed seem hardly able to tolerate the usual 20–45 minute medi-

tation sessions, since in that length of time it is reasonable to expect their

attention to come and go, as they tend to be distracted by external stimuli

(especially auditory) and internal ruminations. One of the cognitive deficits

often found in these patients concerns in fact the ability to keep their atten-

tion focused on an internal or external object
(Wykes & Reeder, 2005).
This would thus increase the risk of patients’ exposure to the “voices” that, not

yet understood and adequately dealt with, may in turn cause anxiety, deter-

mining, as already proved
(Birchwood & Tarrier, 1992),
a condition of stress that might trigger delusions and hallucinations. Meditation itself might then

be experienced as extremely hard and stressful, discouraging patients from

engaging in it again in the following sessions.

During the first experimental phases with a group of ten patients, I remem-

ber one of them saying, after a session of about 25 minutes:

Doctor, everything is so strange: during the first few minutes I was feeling

calm and could follow your instructions, then I heard a voice (external?)

telling me not to do that. . ., saying you were deceiving me and if I had kept

breathing that way I would have activated the device I have in my head. . .I

was scared
.

This example shows how, if all necessary precautions are not taken, even

the experience of meditation may be encompassed in a patient’s delusional

world, so it should be introduced and offered considering everything that

was said about the use of CBT with psychotic patients (Chadwick, Birch-

wood, & Trower,
1996).

Another very useful variation Chadwick introduced is to
avoid prolonged

silence
during sessions. Therapists will indeed give short instructions to

patients during practice, in order to continuously stimulate their attention,

preventing them from going astray in their (delusional) inferences and/or

ruminations, which might increase, rather than lower, their sense of alien-

ation, not belonging and detachment from the real world.

For the same reason, continued practice at home will not be recom-

mended to all patients, especially at the beginning of therapy, especially in

the case of someone is thought not to have sufficient metacognitive, decen-

tring and self-mastery skills. Another good reason to share this experience

with a therapist is that its relational component can be seen as a means and

a chance for patients to increase their sense of sharing and belonging to

the human assembly, while alone in their homes, in a family environment

where tranquillity and understanding are not always guaranteed, they would

Chapter 18 Mindfulness and Psychosis

361

be exposed to the risk of being pointed out and judged as “
the ones who do

strange, unfathomable things
” and are again different.

Hence, we believe that getting involved with a group practice is the best

way to start out, yet not until a therapeutic relationship has been consoli-

dated in an individual therapy setting, where the therapist has gained reason-

able knowledge of the patient’s possibilities and, most of all, not before the

patient is able to fully trust his/her interlocutor and his/her level of clinical

stability is acceptable.

Therapists will have to take care not to proceed too fast when offering

this new type of experience and only after having provided sufficient expla-

nations of its nature and of the intended outcomes.

This psychoeducational approach will be further extended to family mem-

bers, should patients be encouraged to do some short practice sessions

at home.

In the fullness of time, patients who seem to be in good contact with real-

ity, but find it difficult to concentrate on their breathing (as too much of an

abstract task), can be invited to focus on what they do for themselves. They

can be asked to perform a few everyday actions with greater awareness and

especially those tasks that are more gratifying and make them feel somehow

enriched and satisfied. For example, it can be suggested that they pay more

aware attention to what they do:

“Now I am walking,” “Now I am touching the door handle,” “Now I am bring-

ing the toothbrush close to my mouth,”
and so on.

This has a double effect: helping them learn how to recognize themselves

and to focus their attention, where they want it, with little effort, as too hard

tasks may, in case of failure, further weaken their sense of personal worth

and self-esteem; and it also leads them to find out how they can take care

of themselves in a simple way, giving importance to their small everyday

actions and contributing in this way to form a new, more positive image of

themselves (“
I am able to do something for myself and feel satisfied from

it
”), not having to say to themselves they have to change or do something

different, but just noticing and revaluing what they already do spontaneously.

In other words, learning to accept themselves for who they are and what

they do, no matter what it is and how it is done.

As for defusing from the voices, we find the hints provided during the

fourth MBCT session extremely useful
(Segal et al. 2002).

The protocol involves a “mindfulness of sounds” moment, designed to

increase awareness of sounds through the practice of mindfulness (see

also Appendix A of this volume). In order to keep patients from getting

stuck on the contents of voices, which are known to trigger emotional and

behavioural responses, we invite them to pay attention to some of their for-

mal components, such as tonality, timber, pitch and length, as well as the

rhythm they make as they come one after the other. This encourages patients

to do the opposite of what they would normally do, that is avoiding or being

afraid of the voices. In fact the aim is to arouse their curiosity to observe them

in a different way, to catch some details and finding out particular aspects

they had never noticed before, living in the present moment and refraining

from any evaluation; just noticing them and, in case they find themselves

lingering on their possible meaning, they should gently drive their attention

362

Antonio Pinto

back to their sensory features, trying not to blame or come down on them-

selves for not doing the exercise the right way.

In this way, patients are helped to change the way in which they deal with

misperceptions. They will realize that they do not just have to suffer them,

but can decide whether to amplify them or not, or whether to observe or

ignore them.

Moreover, this occasion shall be used to reinforce the idea that what is

important is the process, not the outcome, and that managing to give up

the idea of
having to do things well
, while pointing out that of
just doing

them
, will be a further step towards moving from
doing mode
to
being mode

which is itself an object of focused awareness.

The Heterogeneousness of Clinical Pictures

As already mentioned before, the extreme heterogeneousness of symptoms

and phenotypic pictures has to be taken into consideration when planning a

therapy. Patients with structured delusions, but no formal thought disorder

or hallucinations present different issues from those with a prevalent hal-

lucinatory component or with low social functioning and/or high levels of

cognitive impairment.

In our opinion, group therapy should always aim at improving clinical con-

ditions, groups should never be uneven, as this makes mutual acceptance

and sharing much harder to learn and may instead increase patients’ sense

of otherness and non-belonging, as well as their fear of being criticized or

judged.

After a session of group practice, a patient asked if he could talk to me in

private:

Doctor, as I was trying to concentrate on my body and on my breath, trying

to release every unpleasant sensation related to the voices, I felt embarrassed

and anxious thinking that my experience was totally unknown and not very

understandable for the others. . .so I thought that if this makes me so tense,

maybe it is not good for me
.

Another one told me “
he could not understand why I was considering

him similar to those mad people hearing things that were not there and

how he could possibly trust them. . .
”

If on the one hand we try to help patients develop a habit to relate mind-

fully to all experiences, including the psychotic one in general, it is also true

that this is a goal, not a requirement, and patients must be placed in a condi-

tion in which they can achieve it.

In this view the grouping of patients with similar symptoms can be useful,

as this will make them feel less exposed to criticism and embarrassment.

If all group members share the same kind of sensory experiences or the

same issues, i.e. relational (let us think, as an example, of the tendency to

relate to others through the lenses of persecutory ideas), it is more likely that

they will reach acceptance of their present experience without judging it.

We shall not forget that, even in the best-case scenario, these patients have

a labile illness insight, so it is not always possible to count on their accep-

tance of explanations for the origin and nature of their thoughts and experi-

ences.

Chapter 18 Mindfulness and Psychosis

363

In other words, what we consider a psychotic experience is, for many

patients, the ordinary, self-evident, irrefutable one and the only way to per-

ceive reality and interpret facts.

A further issue that shall not be neglected is that these patients may lose

their sense of time and space and, eventually, even of their own physical

boundaries.

Hence, it is important to evaluate if a patient should or should not be asked

to close his/her eyes during practice. An alternative to closing their eyes can

be the focusing on a point on their chest and/or keeping one hand either

on their chest or abdomen, in order to help them feel their body and follow

their breath.

Finally, it can be suggested to patients who easily fall into a delusional state

or who are noticed to have an increased sense of otherness after even very

short sessions, that they concentrate their attention on the movements of the

chest of who is in front of them and try to be in tune with their breathing

(Chadwick, 2006).

DV-SA Questionnaire

We invited our patients to perform a self-administered questionnaire on sub-

jective opinion about delusions and voices (
DV-SA questionnaire
: delusion

and voices self-assessment questionnaire, Pinto, Gigantesco, Morosini, & La