Clinical Handbook of Mindfulness (95 page)

forms that are validly structured for other pathologies (i.e. depression, anxi-

ety and so on). It is therefore necessary to briefly overview the main features

of psychosis, in order to better understand its intrinsic nature and identify

which strategies can be used to adapt the basic principles of mindfulness in

a way that better suits the needs and characteristics of patients, in order to

achieve the best possible outcomes.

Chapter 18 Mindfulness and Psychosis

341

General Characteristics of Psychosis

Psychoses and schizophrenia, in particular, are no doubt in a position of

prominence among the above-mentioned highly complex pathologies. They

are a series of severe psychiatric disorders, characterized mainly by an altered

perception of reality, up to a profound loss of contact with the surrounding

world and lack of illness insight, which in severe cases can even be total.

Through the years, there have been several attempts to identify the basic

diagnostic criteria of schizophrenia. Today, despite these attempts, various

controversial points remain. However, it is generally accepted that disor-

ders of thought form and content, loss of functional abilities and a particular

course over time are psychopathological aspects common to various forms

of psychosis.

Schizophrenia is characterized by a series of symptoms, such as halluci-

nations, delusions, disorganized thinking, affective flattening and catatonic

behaviour. Symptoms must persist for at least 6 months. Moreover, cogni-

tive functions may deteriorate over time
(American Psychiatric Association,

2000).

We, however, emphasize the importance of considering the extreme vari-

ability of phenotypic manifestations of schizophrenia for diagnosis and ther-

apy purpose.

Indeed, if it is true that this disease has a negative course in the long run,

psychic deterioration should be lower at an early stage, which means higher

possibilities for intervention. On the other hand, patients with a long history

of illness should be likely to have more severe cognitive and social/functional

impairment
(McGorry P.D., 1999).
Moreover, as suggested earlier, the level of illness insight can vary greatly from patient to patient and, even complex delusions do not necessarily prevent communicating and sharing at

least some aspects of reality. Finally, we should not forget the great vari-

ety of clinical pictures among the forms of schizophrenia with prevailing

positive/negative symptoms or with alterations in the formal organization of

cognitive architecture, rather than in the contents of thought, which causes

extremely disorganized and confused cognitive and behavioural manifesta-

tions
(Andreasen, Arndt, Alliger, Miller, & Flaum, 1995).

Today it is widely accepted that schizophrenia is a mental disorder or a

series of diseases transmitted genetically and/or caused by perinatal or pre-

natal traumas
(Weinberger D.R., 1987; Roberts G.W., 1991).

For many years, the idea of schizophrenia has been affected by Kraepelin’s

approach, which found its basis on a pejorative course that would culminate

in a dementia-like picture
(Kraepelin, 1919).

It was therefore seen as a disease that would basically have a chronic

course.

The dogma of a progressive devolution of the pathology has contributed

to a climate of mistrust and pessimism among both therapists and patients’

families. Such approaches have resulted in orienting therapeutic choices

towards the isolation of the subject from his/her social environment (espe-

cially before neuroleptics were used) or in the attempt of containing the

patients’ disabilities, seen as obstacles to their return to the community

and to their possibility to reach normal levels of autonomy and social

functioning.

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Antonio Pinto

Later studies on the course of schizophrenia
(Liddle P.F. 1999)
were determining for a “crisis of the concept of chronicity and presumption of incur-

ability”
(Ciompi & M¨

uller, 1976; Huber G., 1979),
both widely related to

the emphasis given by Kraepelin on deterioration in “Dementia Praecox”

(Kraepelin, 1919).
The two main studies conducted by the World Health

Organization (WHO) on the epidemiology of schizophrenia revealed a wide

range of variations in the course and outcome of this disorder. The Inter-

national Pilot Study on Schizophrenia (IPSS) in particular
(WHO, 1973)

documented how, in a two-year follow-up, only 37 per cent of the sam-

ple evaluated at the beginning was still in a psychotic state, the remaining

two-thirds of the sample could either still present some non-psychotic or be

totally recovered.

Furthermore, today we know how the course and outcome of an

apparently universal phenomenon such as schizophrenia is in fact widely

influenced by factors that do not depend on the intrinsic features of the

pathology. Bleuler himself would say, “
. . .
what is determined is only the

direction
of the course and not the course itself. The outcome is not a fea-

ture of the disorder, but it depends on
actual internal and external factors
”

(Bleuler, 1911).
In support of this, WHO data reveal a better prognosis of schizophrenia in those developing countries with a substantially more supportive family and social environment playing an important role against iso-

lation and stigma
(WHO, 1973, 1979; Jablensky,
1987,
1989,
1992; Sartorius et al.,
1986).

Currently indisputable data shows that the illness course is basically influ-

enced by environmental events and that patient’s environmental modifica-

tion can lead to important effects (Bellack Mueser et al., 1997).

Traditionally, schizophrenia has been the purview of psychiatric treatment,

with
antipsychotic medication
as primary intervention and
psychosocial

rehabilitation
as secondary
(Bellack & Mueser, 1993;
Penn & Mueser, 1996).

Recently, the perception of the nature of psychotic syndromes and the pos-

sibility to positively influence their course has gradually yet firmly changed,

although, for the following reasons, psychotic patients are hardly considered

eligible for radical structured psychotherapy.

Difficulties in Structuring a Setting for Psychotic Patients

•
The first concerns a presumption of incurability
. Generated by the

concept of chronicity. Such an assumption has long represented funda-

mental scientific bias, affecting motivation to engage in serious clinical

research, aiming to identify adequate strategies: it would not be worth-

while to undertake a complex therapeutic treatment, to determine sub-

stantial changes in the patient’s way to interpret reality and deal with it, in

case of a genetically determined pathology that’s inexorably condemned

to evolve (or rather devolve) into a chronic degenerative and defective

process.

•
Excessively protective attitude of mental health centres
. After asy-

lums, mental health centres, in their several divisions, appeared to be a

possible solution to try and contain and possibly uncover some of the com-

plex issues underlying the structure of the schizophrenic phenomenon.

Chapter 18 Mindfulness and Psychosis

343

Mental health service structures found a solid and innovative epistemo-

logical reference point in the vulnerability model, renewing their impulse

towards the care of schizophrenic patients. This shook off psychiatrists’

sense of resigned impotence towards planning a therapeutic interven-

tion programme, so common in the last decades. Mental health service

would thus try its best to protect patients from the risk of a crisis caused

by exposure to a stress they could not cope with, as this would appear

coherent with its reference model; in other words mental health service

and its staff would act as a defensive barrier, preserving patients from

suffering and offering them adequate medical and social support. Yet,

the concrete risk of following the theoretical vulnerability model liter-

ally is to create a sort of “protective belt” around vulnerability, rather

than patients, paradoxically fostering the “
chronicization of vulnerabil-

ity
” itself. Indeed, interventions through standardized and predetermined

programmes, aiming mainly at the remission of symptoms and “normaliz-

ing” of behaviours, show psychiatrists as “
gardeners of madness
,” whose

task is “
pruning
” anything that appears pointless and potentially dan-

gerous (smothering) for a “better” growth of the individual (Lazslo &

Stanghellini,
1993).
Although in a particular historical moment such an

attitude might no doubt have been useful, following the latest scientific

achievements in the psychological and pharmacological field (not least

the advent of atypical antipsychotics), it does not seem to meet the needs

of those who rather believe in the possibility to apply, with schizophrenic

patients as well, the general principles underlying psychopharmaco-

logical and psychotherapeutic treatments used for other psychiatric

pathologies.

•
Difficulties in establishing good relational attunement and build-

ing a solid therapeutic alliance
. Schizophrenic patients very often

appear scarcely willing to be helped, having a suspicious and distrustful

attitude, even displaying outright hostility to the therapist. Furthermore,

while attempting to structure a stable setting for therapy there may often

be a lack of attunement between the therapist and the patient’s needs,

with no apparent possibility for reasonable mediation. At times therapists

and patients seem to be engaged in a rational struggle in which therapists

try to encourage patients’ critical sense in order to increase their sense of

reality, while they are intent on defending at any cost their ideas and own

interpretation of events and surrounding reality. This often causes a gap

between therapist and patient.

More issues compromising the therapeutic alliance are:

Lack of clarity on the goals to be achieved
. Through the years, dif-

ferent types and models of therapeutic intervention with schizophrenic

subjects have been developed, aiming mainly at a remission of the symp-

toms and at a better management of the patient’s dysfunctional behaviours

(Burti, 1993; Hogarty, 1998).
Such interventions are part of the so-called biopsychosocial approach
(Penn & Mueser, 1996)
and range from a

hospital treatment model for crisis management, to the so-called psychoso-

cial rehabilitation, mainly implemented within community-based struc-

tures. In our opinion, such models have not always considered the sub-

jects’ subjective perception of well-being as the main purpose of ther-

apy, nor as one of the outcome indicators that usually trace the specific

344

Antonio Pinto

purposes of a psychotherapy treatment (psychological independence, tol-

erance to frustration, mental flexibility, etc.)
(Paltrinieri & De Girolamo,

1996).

Moreover, as long as therapists consider patients’ main psy-

chopathological symptoms (delusions, hallucinations and bizarre

behaviours), as nonsensical
. Hard to investigate and therefore

hindrances to therapy, they will inevitably convey to patients, intention-

ally or not, the idea that they will not actually improve until they come

around to the fact that delusions and hallucinations are the core issues of

their disease. Patients are indeed likely to make a stand against this, further

complicating the formation of a therapeutic alliance.

Another aspect to take into account when trying to understand the

reasons for the difficulties in starting psychotherapy with schizophrenic

patients is the

•
little attention given to patients’ personal history and dysfunc-

tional assumptions underlying their cognitive structure
, which

might contribute, whether uncovered and investigated, to achieve a better

understanding of patients.

Examples of dysfunctional assumptions may be: constantly being in dan-

ger; being a bad person; not deserving esteem and love; having committed

some sins; being condemned to social isolation or eternal damnation; not

being capable; risking to lose control of their own actions; having to be

the best, never making mistakes; having to pursue perfection at all costs;

associating making mistakes with total failure and so on.

Patients seldom spontaneously express such assumptions, on the con-

trary, the fact that delusions and hallucinations drink in all their energies

(as well as those of therapists) may hold them back from achiev-

ing greater awareness of their origin and relationship with the causes

of their problems. Indeed, these patients have severe communication