Clinical Handbook of Mindfulness (97 page)

patients to perceive how they can be and look at their being without judging

or criticizing it; without classifying or measuring it, or worrying whether

others’ approval of them depends on how many right or wrong things they

do; without having to ask themselves if they can get to be loved, accepted

only if they behave correctly, only in so far as they meet the expectations of

others.

Therapists will try to create a setting allowing much time for patients to

introduce themselves, tell about their stories of fears, wishes, feelings and

irrational thoughts, which are leitmotifs of an existence interrupted in its

evolution by the outbreak of an illness, yet whose framework is perhaps held

together by those core contents that are indecipherable to most people, but

represent patients’ only bridge between a shareable reality and what appears

to be total chaos.

In order to actualize a relational atmosphere that is grounded on this sort

of philosophy of acceptance of the other, it will be appropriate to allow

very flexible time limits to the patient. It will be up to the therapist to show

patients attention, care and therefore importance, besides giving proper

credit to their existential value, starting from adapting to and respecting their

timing and modalities (let us not forget their difficulties with communication

and abstract thinking).

Indeed, more than any other type of patients, psychotic people come from

a history of alienation, sense of not belonging and marginalization from the

rest of humanity, as a reaction to the contents of their thoughts and related

behaviours. Furthermore, as their behaviours would be considered as non-

sensical, their whole existence would end up being devalued.

This would be enough to determine, or at least affect those typical atti-

tudes in the schizophrenic experience, such as shutting oneself away and

withdrawing from the world.

If instead patients experience feeling safe within the atmosphere of a

neighbourly, non-judgmental therapy setting and are helped by the thera-

Chapter 18 Mindfulness and Psychosis

349

pist hold the same attitude towards themselves, their permanent state of

alarm, triggering delusions and hallucinations, is likely to have no more rea-

son to exist.

Indeed, decentred awareness of automatic thoughts of self-reproach and

self-criticism contributes to loosen patients’ defensive stance deriving from

ascribing to others’ thoughts their own negative self-beliefs. Such a metacog-

nitive deficit can easily generate delusional ideas of reference, as well as a

sense of danger and threat. Criticism can be so destructuring and destructive

for the subject that it may come to be perceived as a genuine threat to his/her

physical integrity
(Mills, 2001)
and hetero-aggressive acting out would not then be an unlikely possibility.

On the other hand, establishing a climate of acceptance and abstention

from judgment in a therapy setting will allow patients to experience a

new way to relate with others, finally being able to exchange their views

with someone who is not focused on making them change their minds and

showing them how weird and abnormal their way of thinking is. They will

find someone who is interested in their ideas, feelings, ways of living and

thoughts about themselves; someone who will even be interested in talking

about personal and private aspects such as their body (their physical sensa-

tions, their way of breathing, etc.) or their life-plan with its values, purposes

and goals.

This attitude, grounded on compassion and understanding, is one of the

necessary requirements for patients to find, later on, interest and motivation

in putting their ruminations aside for a while, in order to focus their attention

on relating to someone else, starting from the therapist, who will show them

(rather than teach them) how to deal with themselves and their actions in a

different way from what they are used to
(Allen & Knight, 2005).

The “
loss of intersubjectivity
” is often fed by the fear of others, who

will judge and rate them. On the contrary, a more compassionate attitude

towards themselves is likely to affect their state of mind towards people

around them, experienced as threatening and dangerous until then. Greater

openness towards others, meaning less distrust and greater concern about

their needs and difficulties, starts a virtuous circle leading patients to also

receive positive feedback
(Allen & Knight, 2005).
Their sense of personal worth and mastery can increase as they begin to develop decentring skills

and attention to others, since in this way they can experience being able

to feel compassion for someone who is other-from-self, as well as feeling

attending and caring, therefore able to take an interest in and worry about

someone else.

In this kind of setting, the gap between patients and people around them

should narrow, making it easier to create an existential bridge between them,

as people who encounter one another to share an experience, who do not,

at the time, construct hypotheses or evaluate actions and behaviours. An

“
encounter
” is a clear example of a shared experience, representing both

the starting point and the goal of this first phase of therapy. The encoun-

tered is an
alter
not an
alienus
; an alter with whom harmony and syn-

chrony of intents is possible, an alter who breathes and walks with us so

we can recognize him/her as similar and trust him/her, instead of being

afraid. In other words, patients are helped broaden their sense of sharing and

belonging.

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Antonio Pinto

If this emotional state is reached, it will allow us to proceed with less diffi-

culties and “resistance” towards a phase that involves more actively address-

ing sensory experiences and ideative ruminations in a “defused” way, up

to the use of cognitive restructuring techniques and/or learning new social

and behavioural skills through the integration of other structured treatment

approaches, CBT firstly.

Accepting Patients’ Ideas

One of the goals of a mindfulness-based therapy is having patients see how

their suffering and discomfort do not come from the symptoms themselves,

but from how they react to them and what they decide to do (or not) in

order to try and overcome or suppress them.

Patients should for instance be explained that
thoughts are just thoughts

and
voices are just voices
, therefore they don’t have any power to harm

(Pankey & Hayes, 2003).
Similarly to the already validated mindfulness programmes for depression
(Segal et al., 2002),
patients are expected to slowly manage, through practice, to defuse from ruminations and unpleasant feelings, stop automatically making negative assumptions about themselves and

their own discomfort, as well as having reactive behaviours which, in turn,

increase their discomfort or end up being its main cause.

On the contrary, we believe that in the first phases of therapy, thera-

pists cannot and should not try to get across the message that (delusional)

thoughts are only thoughts, and what makes them suffer is just how they

react to them, for such a message might be misunderstood by these patients.

They indeed do not always have those cognitive and metacognitive skills

that allow understanding of what is being explained to them, experiencing

it in a defused way. Any patients adhering to the content of a delusional idea

and initially showing no insight are likely to find it illogical and nonsensical

to consider that thoughts are not troublesome. In our opinion, this would

undermine the therapeutic alliance, so fragile at first, since the theoretical

stance of the therapist would appear to be the same as that of the rest of the

world, which seems to say “your ideas do not deserve to be considered, as

they are just nonsense.”

We indeed know that psychotic patients can be totally absorbed in their

world, both from a sensory and ideative point of view, structuring and per-

forming their own way to interpret reality, come into contact with other peo-

ple, their own categories of meaning and their ideas about self-evaluation.

It is important to take adequate precautions to ward off the risk that

patients doubt that the therapist’s attempt to help them distance themselves

from behaviours and ways of thinking that cause them to suffer is in fact a

polite way to invalidate their core mental constructions (i.e. “
it is not me

who is an inept, they want me to make mistakes
”).

One of my first patients suffered from paranoid psychosis, having strong

feelings of persecution; when I tried to use “standard” mindfulness proce-

dures with him, after a few sessions he would say: “
There is something

wrong with this place, doctor . . . I don’t feel safe . . . they must have man-

aged to locate me . . . they are powerful . . . I think they’re influencing you

too
”
. . .
I realized that he was going into a state of alarm that was not appar-

ently justified by what we were actually doing, but in fact I had been going

Chapter 18 Mindfulness and Psychosis

351

too fast. My patient was not ready to start relating to someone in a way that

was not known to him. He would not trust that someone might want to help

him, but most of all he would not trust himself. My attitude, so finely focused

on finding out what was underneath his delusion, would only reinforce his

already strong sense of inefficiency and his low self-esteem, layered during

the long years of a tormented existence, along with its emotional and rela-

tional failures.

We must take into account that these patients are structured in a way

that necessarily leads them to continuously deal with concepts (automatic

thoughts and cognitive schemas), which are represented (also as metaphors)

within delusions and which they are closely tied to. Thus, we should extend,

at least at the beginning, our attitude of acceptance and acquisition of aware-

ness without judgment to the contents of the psychotic experience itself,

showing patients that we believe they are worth listening to, being believed

and taken seriously for what they think and believe to be correct, as we

would do with any other human being.

If for instance we assume (or notice) that the voices patients hear or

their delusional thinking represent ideas of low self-esteem or personal value

(i.e. insulting voices), we will try to highlight these aspects and prepare

patients to change their attitudes, developing greater tolerance and compas-

sion towards themselves. In this case, as shown by CBT, attention will not

be focused on symptoms like voices or delusional ideas, but rather on what

they represent. Learning to have a more compassionate attitude means help-

ing patients develop greater tolerance towards those aspects of themselves

they consider as negative and responsible for their own condition of life.

Even people with such characteristics can learn to love themselves more just

the way they are and, once they do, they will experience a more peaceful

and quiet, less stressful inner condition.

In order to prevent relational deadlocks during therapy, especially when

it is still to be consolidated, it is appropriate to pay maximum atten-

tion to patients’ history, having them perceive our willingness to try and

understand together what happened or what is happening with them,

placing their (psychotic) experience within their walk of life, whose key

stages should also be re-enacted together, if possible, assuming that they

would lead to some useful elements for a better understanding of present

issues.

This will of course be done in an atmosphere of compassion, empathy

and sincere interest for patients’ feelings and the suffering caused by their

situation.

The analysis of delusional contents, performed with the patient, may allow

the therapist to identify problematic areas showing the existence of specific

dysfunctional assumptions patients have made about themselves, others and

the world
(Beck, 1970).

Therapists can help patients focus their attention on themselves in order

to find the significant past life events in which certain ideas emerged for

the first time, as well as other events contributing to maintain and reinforce

those ideas
(Beck, 1976).

It will be therefore crucial to begin such exploration starting from the

subject’s early childhood, studying: (a) the attachment style within the early

relationship with parents (“parenting”); (b) the creation of “internal working

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Antonio Pinto

models”
(Liotti, 1995);
(c) the presence of deficits in several metacognitive activities
(Guidano & Liotti, 1983).

The themes to be explored will perhaps not yet be totally clear to

patients: what they think about themselves, of their personal worth, their