Clinical Handbook of Mindfulness (99 page)

programmes, as patients’ lives can often be unsatisfactory because of their

difficulties in achieving goals
(Kendall, 1984).

Training in
problem solving
can be of great help for patients to give up

adopting avoidance strategies with any issues they consider to be unsolvable.

They will in fact experience the necessary skills to do what people normally

do, as soon as they learn how to better tolerate initial feelings of anxiety and

discomfort, being then able to use adequate strategies to tackle one obstacle

at a time. This will nurture their self-esteem and sense of personal worth,

further motivating them to continue therapy. In this view, even simple
social

356

Antonio Pinto

skills training
, opportunely revised, can be a valid tool (Bellack, Mueser,

Gingerich, & Agresta,
1997).

Moreover, in theory, an increased sense of personal worth and mastery

may in turn determine an increase in self-esteem and, therefore, reduce

patients’ sense of isolation and non-belonging, which is also fed by the lack

of sharing of even the most common aspects of everyday life.

In order to achieve this goal, patients can be trained to first identify and

then give up those strategies that merely aim at controlling their emotional

states and, subsequently, recognize and accept any thoughts and troublesome

feelings, simply by becoming aware of them in a decentred way, not having

to strive to suppress them. This will help patients to notice how having been

long focused on symptoms had interfered with their life projects (Hayes,

Kirk, & Wilson,
1999).

Patients are though not only absorbed in their own unpleasant feelings but

also chastise themselves for feeling something they should not be feeling.

Non-acceptance is the cause for an exponential increase of suffering, which

in turn is fed by patients’ conviction that symptoms have some obscure

power and therefore have to be suppressed at any cost. This triggers an inner

struggling, fostering isolation and loss of common sense, which leads to a

spiral of increasing separation from reality, becoming the theme of patients’

unshareable malaise.

A therapy that involves offering patients the described relational experi-

ence is a means for promoting the idea that self-acceptance is the missing

ring in their search for sense and meaning. There may though be hindrances

to accepting unpleasant feelings and unusual sensory experiences; patients

might indeed find it hard to “
let everything go
” (that is stop giving seri-

ous consideration to the content of “thoughts” and “voices”), as they might

expect negative consequences from giving up their fight, or, they may be

so used to staying anchored to such perceptions that they are afraid to lose

some fundamental element of their life
(Chadwick, 2006).

Therapists will have to discuss with patients the fact that acceptance does

not mean avoidance of an issue or passive resignation about what they iden-

tify as a cause for their suffering. On the contrary, they will be encouraged to

stick to reality for what it is. Accepting everything that happens within their

sensory range means “
this is my experience and my reality, now
” and this

inescapable fact can be a good basis for developing non-judgmental thinking.

S
elf-acceptance
is, indeed, obviously thwarted by our negative self-beliefs.

Mindfulness can also help increase awareness of our own reactive judgments,

which, just as emotional responses, can be addressed as understandable and

transitory: they can be seen as a part of the self that comes and goes but is

actually not the self.

Thus, having “bad thoughts” does not mean being a bad person, but

just that “
in this particular moment, for some reason, I am having these

thoughts
” and they will pass away and will be replaced by others. They do

not determine my way of being or my actions, but I can turn away from them

if I want.

The fact is that some patients find it very difficult to maintain a mindful

attitude towards psychotic experiences.

What can we do with them?

Chapter 18 Mindfulness and Psychosis

357

Chadwick suggests that they should be reminded that everything they feel

or sense is doomed to pass away; at the same time their decentred awareness

of any feeling, sensation or reaction should be validated and, moreover, they

should be encouraged to keep connected to their body and to breathing in

particular
(Chadwick, 2006).

Yet, it will still be likely that patients feel they have failed once again

and that their inadequacy makes it impossible for them to follow the

programme. This may in turn feed their tendency to ceaselessly make nega-

tive self-judgments. Therefore, great emphasis must be given on the fact that

trying to achieve a condition of acceptance of unpleasant feelings, as well as

subsequent physical sensations, is in fact a process to follow, rather than a

goal to achieve.

Patients will slowly and gradually be guided along the path to awareness

and their constancy and perseverance will continuously be encouraged in

order not to let them feel discouraged. Any difficulties, i.e. being distracted

by intrusive thoughts or voices will be normalized and shared.

We might as well invite patients to deliberately expose themselves to

their bizarre thoughts or disturbing sensory experiences, obviously trying

not to transform, control or understand them, but just awarely noticing

them.

Later on, it will also be possible to help patients release the literal content

of thoughts, through a process of cognitive defusion
(Luoma & Hayes, 2003).

They will be once again reminded that thoughts do not have any power to

directly transform reality or determine our behaviours.

Thoughts are in fact just thoughts
. The essence of defusing techniques

is getting accustomed to seeing thoughts and feelings for what they are

(just experiences), rather than what they seem to mean (structured realities)

(Bach & Hayes, 2002).

A Sense of Bodily Fragmentation

Another common issue among these patients is their sense of fragmentation

and destructuration, mainly located in their body in the form of an altered

coenaesthesia. An altered perception of the body scheme has been reported

in highly stressful interpersonal contexts, such as families with high levels of

expressed emotion where communication is extremely disturbed and con-

fused, characterized by high hostility and criticism that are conveyed through

improper use of verbal language tones and contents. This causes patients to

constantly feel in danger or even physically threatened and, in psychological

and/or physical trauma patients, such clinical manifestations take the struc-

ture and defensive meaning of dissociative states.
(Falloon, 1988;
Kuipers & Bebbington,
1988).

Furthermore, these patients’ cognitive deficits often prejudice their ability

to quickly and properly decode words
(McKenna & Oh, 2005),
so their only way to find a meaning in what happens around them is by holding on to

what comes from their body sensations and emotional states: feeling scared

or terrorized, besides having intense physical sensations they cannot account

for and which, in turn, become causes of further fear and concern. In this

way, their initial state of alarm will be amplified.

358

Antonio Pinto

It is thus likely that patients construct multiple, not integrated mental rep-

resentations of self, so their sense of bodily fragmentation may be intended

as a metaphor for something that would otherwise be impossible to commu-

nicate.

Indeed, in this search for sense and meaning, it will be useful to set body as

a starting point, in order to help patients develop a more mindful relationship

with it
(Mills, 2001).

Once patients learn to relate with their bodies in a different way, becoming

more aware of their common sensations, including the pleasant ones, they

more easily manage to also transform their relationship with stressful and

unpleasant sensory experiences.

Case Report

A patient we can call “John” suffered from severe paranoid schizophrenia.

He would live in a condition of significant social isolation and relational

impairment. The only activity he could engage in was bodybuilding, of

which he had become an eager practitioner. His father, who wanted to try

and encourage him to broaden his interests, would oppose this only pas-

sion and this triggered violent family fights with bitter criticism. Immedi-

ately after these high-pitched arguments, John would feel deep anxiety and

anguish, as well as a strong sense of danger and threat. He would also bring

up an increasing sense of bodily disaggregation, “as if my body would break

into pieces.” He could not feel it anymore, nor he could tell which was its

position in space; he would feel his blood disappearing from his veins, “as

if someone had been sucking it out.” After a while he would see his father

“turning into a monster. . . a sort of vampire.” At that point, he could not do

anything but run away, making them lose track of him, and would usually

be found after a few days in confusional state
.

In fact, when under stress, John could not decode his own high levels of

tension and anxiety and, as a consequence, he would construct mental rep-

resentations of a physical identity, based on a misinterpretation of physical

sensations connected to fear and to feeling threatened. His psychotic struc-

ture would then lead him to make up a world, as well as intrinsically coherent

meanings, that could provide the necessary explanations for him to choose

which behavioural steps to take.

Managing to keep their attention focused on their body and on catching

and enhancing every sensation coming from any specific district of it; being

fully aware of their senses, moment after moment, can distract them from

feeling overawed and devastated by terrifying and disaggregating thoughts

and feelings that hamper their full and fluent relationship with reality.

This kind of concentration is not a mere exercise of the mind, but a

renewed ability to develop a new sense of the self. Patients with a weak

ego unity and stability will take advantage of the practice of “
body scan
” or

“
mindful walking
”
(Kabat-Zinn, 1990;
see also Appendix A of this volume).

They will be invited to notice everything that happens, everything they per-

ceive and every body sensation; they will be asked to notice what comes up

and concentrate on their mental representation of what they are perceiving,

just noticing, without commenting.

Chapter 18 Mindfulness and Psychosis

359

This will help the process of “
embodiment
” and regaining of patients’

sense of corporeity, threatened by their feelings of fragmentation, and will

foster a more competent and stable sense of the self, protecting them from

a disaggregation and dissolution of their ego, otherwise they would find in

delusions the only way to give events a meaning.

Being in motion, as a unitary organism, held together by the ability to

perceive all sensations, elicits the impression that different parts of the

body are connected to each other and communicate with each other. The

fragmentation these patients report is not simply an abstract idea, but an

actual physical sensation. Experimenting a new, more aware way to be in

motion, feeling more centred and relate to the surrounding world in a new

way, can help transform one’s “being-in-the-world”
(Mills, 2001).

Indeed, everything concerning corporeity can by right combine to bring

about self awareness or, in other words,
presence
; yet not for its own sake,

within the boundaries of a more or less defined body scheme: body can be

a means for connecting with others:
the body I am
, a subject-body, makes

encounters with other subjects bodies possible and is opposed to
the body

I have
(Callieri, 1989),
an object-body that, according to the constrained and petrified psychotic meanings is object of spells of violence and is anyway passive towards anything coming from who is other-from-self. See the

enlightening pages by
Merleau-Ponty (1945)
on this subject.

Being able to experience areas of well-being, as well as a different way

to perceive oneself, one’s corporeity and sensations through an aware and

intentional use of the described practice can therefore help increase self-

esteem, as well as a sense of empowering connected to having developed

a focused awareness as an alternative to being swept away by the ceaseless

torrent of thoughts. In other words, focusing on one’s self and one’s own cor-

poreity can be an opposite experience to fragmentation, providing a sense