New Voices: Should we be more mindful of psychosis?

How many times have you sat down to have a cup of tea or coffee, only to realise that you have finished it without even being aware that you drank it? We live in a culture where we feel we always need to be active, whether it is being immersed in technology and social media, reading up on the latest theory or rushing around in a desperate attempt to balance work and home life. Perhaps if we were more aware of the present moment, we might find it easier to concentrate, become more attuned to ourselves and others, and more resilient. Are we 'mind full' or 'mindful'?

Mindfulness is an ancient Buddhist practice that involves 'paying attention in a particular way, on purpose, in the present moment, and non-judgmentally' (Kabat-Zinn, 1994), helping us become more aware of our thoughts and feelings, and managing them in a better way. It is about waking up to the present moment, reconnecting with ourselves, and appreciating the fullness of every moment. When we go on 'autopilot' to process our emotional experiences we can lose sight of them and become detached and disconnected from ourselves. Mindfulness techniques help people become more aware of the way they think and feel, and how their experiences impact on their emotions.

There is evidence that mindfulness practices can lead to reduced suffering and enhanced well-being (see Baer, 2003). Many of these techniques have been incorporated into well-researched treatment approaches for a range of mental and physical health difficulties, such as mindfulness-based stress reduction (MBSR), mindfulness-based cognitive therapy (MBCT), dialectical behaviour therapy (DBT) and acceptance and commitment therapy (ACT).

These approaches have been described as 'third wave' therapies because they go beyond first wave behavioural, and second wave cognitive-behavioural techniques that emphasise thoughts themselves. Instead, they focus on changing how people relate to their thoughts. Integrating ancient wisdom and modern science, mindfulness is emerging as a powerful evidence-based tool, shown to be effective in clinical settings to alleviate a variety of mental health problems and to improve psychological functioning (Baer, 2003).

Although mindfulness has become a commonly used approach in the treatment of less severe psychological problems, the feasibility and effectiveness of mindfulness-based interventions in the management of serious psychiatric disorders remains controversial (Segal et al., 2002). For example, teaching meditation to people who experience psychotic symptoms, such as hallucinations and delusional beliefs, has been discouraged, with some people arguing that deep states of absorption may be linked to the onset of hallucinations in people who are prone to psychosis (Yorston, 2001). However, these papers refer to single cases, lack experimental rigour and mostly refer to lengthy transcendental meditation practices. Modern therapeutic approaches consist of shorter breathing exercises and teach mindfulness as a 'choiceless attention' rather than a concentration meditation. There is increasing evidence that specially adapted mindfulness techniques can be used safely and effectively in the management and treatment of severe mental health problems, such as psychosis (Chadwick et al., 2005; Langer et al., 2012).

Psychotic disorders, such as schizophrenia, are often chronic conditions that cause considerable distress and functional impairment. People who experience psychotic phenomena such as auditory hallucinations often, although not always, find these symptoms greatly distressing. As a result, they may engage in avoidance strategies (such as suppression or distraction), or on the other extreme, can become engrossed in their symptoms (ruminating or confronting them). Both of these reactions are associated with increased distress in relation to psychotic symptoms (Badcock et al., 2011; Romme & Escher, 1993). However, strategies that include paying attention and acceptance are associated with reduced distress and a greater ability to cope. For example, Romme & Escher (1989) found that the most effective coping strategies used by people who hear voices involved listening to them and accepting them, which was related to a more positive view of the self.  

Therefore, mindfulness skills can provide these individuals with an alternative way of relating to their symptoms, moving from a judgemental and controlling stance to a more compassionate, accepting view. The effectiveness of mindfulness-based approaches for people with psychosis has been demonstrated in controlled clinical settings (Jacobsen et al., 2011) and in the community (Chadwick et al., 2009).

How does this mindful relationship with psychotic sensations unfold? Abba et al. (2008) argue that it's a three-stage process:

I    Learning to become more aware of psychotic experiences and observing the thoughts and emotions that follow them.
I    Allowing psychosis to come and go without reacting in order to cultivate the understanding that distress is produced by the meanings one attaches to thoughts and sensations.
I    Reclaiming power by accepting psychosis and the self by acknowledging that the sensations only form part of the experience, and are not a definition of the self.

Through these processes, mindfulness practice reveals that judging, ruminating and struggling against psychotic experiences creates distress, while observation and acceptance of psychotic experiences in the absence of judgement is empowering and calming. By relating mindfully to sensations by paying attention to emotional reactions, clients discover that thoughts, images and sensations are transient and temporary; that they are a product of the mind, rather than a part of the self. These techniques enable clients to understand that they have a choice in how they respond. This realisation can help them to break free of habitual reactions to these experiences (such as negative self-judgements), reducing distress associated with them.

However, the introduction of mindfulness can present a challenge to change-oriented cognitive and behavioural therapists, largely because of the acceptance-based nature of the techniques (Lau & McMain, 2005). There is no attempt to dispute dysfunctional cognitions, but to be non-judgemental and to accept thoughts, feelings and sensations as they are. Paul Chadwick has demonstrated that these approaches can be effectively combined in mindfulness-based cognitive therapy (MBCT) for distressing psychosis (Chadwick et al., 2005). In MBCT, as well as being more aware of thought patterns, clients are encouraged to observe and accept their internal experiences, and how they influence thoughts and behaviour. Cognitive change appears to result from understanding that thoughts and feelings are temporary phenomena which will pass eventually, and embracing and cultivating an attitude of acceptance can enhance the therapeutic relationship, clients' acceptance of self and others, and therapists' acceptance of clients. In this way, acceptance strategies can lead to behavioural changes, and help the integration of two seemingly contrasting approaches, with promising outcomes.

There are also some exciting findings to suggest that mindfulness practice is associated with physical changes in the brain. Structural changes have been observed in the anterior cingulate cortex, which is an area of the brain associated with emotional regulation (Tang et al, 2012). These changes are associated with improvements in mood, which is consistent with emotional regulation being a core feature of many mental health problems, including psychosis. There is evidence to suggest that mindfulness practice is linked to reduced brain activity in the default mode network (Brewer et al., 2011). This network of brain areas is believed to be involved in rumination and mind wandering, which are common thought processes seen in people with mental health difficulties. Becoming more aware of the present moment through mindfulness practice is associated with a reduction in these mental states. Components of many psychiatric disorders, such as psychosis, are preoccupation with thoughts, rumination and poor emotional regulation, which mindfulness practice appears to affect. Neuroimaging studies are beginning to explain the neural mechanisms of how mindfulness might be working clinically.

A few years ago I was fortunate enough to work with a psychologist in a rehabilitation team who was running a mindfulness group. I was amazed to see how beneficial people found the techniques for coping with symptoms such as hallucinations and paranoia, and how much more prepared they felt upon discharge from the team. I am keen to continue this work, so currently I am investigating the effectiveness of mindfulness-based group therapy in an Early Intervention in Psychosis Service in London, helping people learn new ways of managing and living with their difficulties. I am also eager to extend my work to explore the neuroscience of mindfulness, particularly the link between mindfulness practice and structural and functional changes in the brain.

In sum, mindfulness is a new, powerful technique with a rapidly growing evidence base for reducing distress associated with a number of mental health problems. It can complement and enhance the effectiveness of existing psychological treatment approaches and offer a way to develop insight, empathy and tolerance. As a worrier myself I am very aware of the impact of dwelling on negative thoughts and anticipating the worst! Learning about mindfulness has enhanced my personal and professional development, and it can help practitioners as well as clients value every moment and appreciate the richness of life.

Carly Samson is a Research Worker at the Department of Psychosis Studies, Institute of Psychiatry, King's College London
[email protected]

References

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