Two ways of being with & treating Psychosis

Show how a different presenting problem or issue can be formulated from two different theoretical perspectives and examine the implications of these different formulations for practice.

(Final essay question on the ‘independent route’ exam for Counselling Psychology Chartership, 2001)

 

Introduction

For a presenting problem/issue I have chosen the incidence of a sustained first psychotic episode. I will examine formulation and treatment of the problem from a perspective typical of a community mental health team (assessment / diagnosis /treatment: possible medication and /or CBT), and from the perspective of a transpersonal therapist alert to the possibility that the issue may be one of ‘spiritual emergency’ (Grof, 1985). The former perspective is firmly embedded in the medical / scientific, western psychological tradition; the latter is more of a hybrid of western and eastern psychological principles which recognises, as a first assumption:

 “That our usual state of consciousness is sub-optimal”

(Walsh & Vaughn, 2000)

The presenting issue will remain ambiguous – my own subjectivity will not allow otherwise! I am exploring a psychotic episode that I myself experienced over twenty years ago. The ambiguity is best framed using Wilber’s (1980 ) concept of the ‘pre-trans’ fallacy. A key assessment question being “ Was the psychotic episode a symptom of ‘pre-personal pathology’ or was it indicative of an ungrounded foray into transpersonal levels of awareness?” I shall leave these questions to the formulations of the putative therapists.

(I shall use this typeface to indicate that I am writing reflectively or speculatively from memory of how it may have been at that time)

This exploration is speculative because I managed my own recovery back into consensual reality – though I was strongly encouraged to seek contact with the local psychological services at the time (both in the USA and UK). I was also offered sessions with a priest who ran a Chinese / Christian church. I was turned down when I sought refuge at the Green Gulch Zen centre[1] – though, where I was living in the Bay area of San Fransisco, I was more likely to meet a transpersonal therapist than any other place on earth. I certainly found the informal psychological support/friendship of an older mentor[2] invaluable.  I shall let more details of my personal case study emerge as we explore the likely formulations and treatments of the alternative therapists. As I open up to this experience again, only to close it down – (as a contribution to the disciplined structure of the essay) – I am aware of a sense of delayed gratification. There is still a frisson of excitement for me to reflect upon this period of time that was both euphoric and terrifying, humbling and self-aggrandising and above all – extraordinary.

 

The Phenomenon of Psychosis

 

‘Psychosis’ is defined in the Oxford English Dictionary as:

“a severe mental derangement, esp. when resulting in delusions and loss of contact with external reality”

It’s a word from the western/medical/psychiatric vocabulary used to describe a cluster of symptoms, beliefs and behaviours that are outside the remit – somehow – of consensual reality. Reality – clearly – is defined by, and from within, cultural context.

“In many cultures, of course, the existence of spirits in the form of visitation from the Gods (as in South America), or in the presence of ancestors and spirits around us at all times (such as in Africa), is an ordinary way of experiencing reality”

(Clarkson, 1992, p. 189)

Clarkson reminds us, too, of psychology’s original roots in philosophy and religion and how our original understanding of madness was based, principally, on the concepts of divine intervention and/or demonic intervention. More recently, however:

The traditional definition of sanity and mental health involves as a fundamental postulate a perceptual, emotional and cognitive congruence with the Newtonian-Cartesian image of the world, which is seen not only as an important pragmatic frame of reference, but also as the only accurate description of reality.

(Grof, 1985, p.396)

Whose presenting issue?

Many people who have experiences described as psychotic do not make contact with mental health services because they do not find their experiences distressing. (Romme & Escher, 1989). Other people do find the experiences distressing but develop ways of coping with them on their own. (Coleman 1999).  And there are others who self refer, or who are referred by their families/friends who clearly are distressed and in need professional help. They are uncomfortable with themselves and uncomfortable with other people. They are probably looking for peace of mind and some way of reducing their social isolation. Then there are those referred to forensic psychologists by the justice system – who’s demise may well have been precipitated by that same social isolation and lack of peace of mind.

Presenting the issue –to who?

A contemporary mental health team will consist of a variety of professionals – there is likely to be an active and ongoing debate between the psychiatrists and the clinical/counselling psychologists around the issue of diagnosis. The latter may be wary of psychiatric diagnoses, arguing that they are no more than labels which describe certain types of behaviour;  that they do not tell us anything about the nature or causes of the experiences. There is a danger that diagnostic categories are assumed to offer an explanation for  unusual experiences, rather than merely a short-hand description of  those experiences.

They generalise and thus deny the individuality and/or the cultural context of the diagnosed person; they also suggest generalised treatment protocols.

The ‘diagnostic model’ for assessing psychotic experience to determine categories of mental illness is still very influential.

Twenty years ago the above arguments were less well developed – had I approached mental health services at that time, I may have been on an express route to a life-long diagnosis. I had recently read Laing, and Szasz; and the film of Keesey’s ‘One flew over the cuckoo’s nest’ was fresh in my mind.

What’s the diagnosis?

Schizophrenia and Bi-polar Disorder are the most common diagnostic categories assigned to people who have psychotic experiences; and traditional psychiatric drugs are by far the most common form of help offered to people with psychotic experiences.

“Neuroleptic drugs may be used in the acute phase of psychosis (when experiences are most intense or distressing). Afterwards, they can be used either intermittently (when the person feels unwell, distressed or under stress) or prophylactically (when the person has partly or totally recovered in order to try to prevent further episodes). For many people, prophylactic treatment can be important in preventing further episodes and hospital admissions. However, some people wish to avoid long-term drug treatment and prefer to use non-medical approaches for coping with psychotic experiences or to use medication only at times when the experiences are distressing. Prescribers need to discuss these issues in a collaborative manner.”

(BPS, 2000. 11.2)

I was not convinced, at the time, of how collaborative a mental health assessment may have been. Had I read that final sentence, it would not have got through my layers of paranoid thinking. I had a great fear of becoming hooked on the ‘need for psychiatric help’. Even during my more rational occasions when reflections upon my own behaviour and the feedback from others persuaded me that I “may be” mentally unwell, I had various self-help strategies in reserve. I was convinced that I must either find my own way to regain equilibrium or capitulate to a life-long vulnerability to mental instability and dependence on the experts. Such starkly polarised thinking may also have been symptomatic, but my self-management of the episode has been followed by half a lifetime of ‘ordinary neurosis’ with no unbidden[3] re-occurrence of psychotic mind-states. Nor have I have had any subsequent fears for my own mental stability; and I find I have a high tolerance for the mental instability of others (both clients and friends).

Talking therapy please

Had I been offered a ‘non-medical approach’ then the most common ‘talking treatment’ available in a mental health team would be CBT. (Gunderson et al,1984) Currently, most people who have psychotic experiences and receive talking treatments also receive medication. A recent review of psychotherapy in the NHS found talking treatments to be as important a component of healthcare as medication, but also found that such treatments are often not made available to people who have psychotic experiences (National Health Service Executive 1996).

Earlier research in the United States, however, has suggested that for some people, psychotherapy can be more effective without medication, and that it can sometimes be more effective than medication alone. (Karon & Vandenbos, 1970).

More diagnoses:

Schizoaffective disorder – symptoms of both schizophrenia and bipolar disorder.

Schizophreniform disorder – diagnosed if psychotic symptoms last more than one month but less than six months. Symptoms are similar to those of schizophrenia.

Drug induced psychosis – brought on solely by the use of drugs in someone who is predisposed to a psychotic episode. With a drug induced psychosis the symptoms appear quickly and last a relatively short time, hours to days, until the effects of the drug wear off. Disorientation, memory problems and visual hallucinations are the most common symptoms.

Delusional disorder – holding strong beliefs in things that are not true: delusions of being persecuted, that people are out to get you, that you are someone famous or ‘a chosen one’

Major depression – a type of depression which is so intense it causes loss of interest and enjoyment, loss of appetite, severe insomnia and even psychotic symptoms- such as delusions.

 

Improvements to the diagnostic criteria

Since that time, and in response to criticisms leveled at both the validity and reliability of diagnosis, the latest DSM IV (APA1994) – updated and refined – includes a new diagnostic category of Spiritual Disorder:

“…used in the event of distressing experiences that involve spiritual values, not necessarily related to a religious institution…takes into account but does not specify near death, transcendental or religious experiences and a host of other events which precipitate an upsetting change of values. These altered states may emanate from states ranging from drug-induced hallucinogenic experiences to religious conversions….if the crisis is a first onset, it is not necessarily treated with drugs, nor considered an illness. For someone undergoing such a redefinition of identity with all of it’s painful wrenches and counter-pulls, an allied and non-intrusive listener might be a welcome ally, as opposed to a distant diagnostician who labels one with a mental disorder and drugs accordingly.”

(Russell, 1994, p.384)

Were I the assessment clinician looking for a diagnosis for my young self as client I would have considered drug induced psychosis but would have favoured schizophreniform disorder – on account of the month long duration of the symptoms. Had I had the benefit of the more recently introduced diagnostic category of Spiritual Disorder I would be considering changing my diagnosis.

The Pre/Trans fallacy

This is where Wilber’s (1983) ‘Pre-Trans’ conceptualisation would have assisted in assessment. Ken Wilber has emerged as a leading theorist in the transpersonal field. He is perhaps best known for his ‘Pre/Trans Fallacy.’ (Wilber,1980) Calling on the evolutionary philosophy of Aristotle, Hegel and Teilhard de Chardin, also of Aurobindo from the Eastern tradition, he develops and elaborates a complex developmental model which – in much condensed form – goes from:

prepersonal -> personal-> transpersonal,  and correlates with:

sub-conscious-> conscious-> superconscious,  and

nature-> humanity-> divinity

Since development moves in such a direction, argues Wilber, and since both prepersonal and transpersonal are, in their own ways, non-personal, then prepersonal and transpersonal tend to appear similar, even identical, to the untutored eye.

Mistakes can be made in both directions – to erroneously describe a transpersonal experience as a prepersonal experience is to make a pre-trans fallacy (1), a ptf1.  Freud made a ptf1 error, maybe, when he dismissed Romain Rolland’s deeply contemplative experience as ‘infantile’.[4] To erroneously describe a prepersonal experience as a transpersonal experience is to make a pre-trans fallacy (2), a ptf2. Jung makes a ptf2  error, perhaps, when he:

“occasionally ends up glorifying certain infantile mythic forms of thought”             (Wilber 1996)

Why is religious/spiritual preoccupation prominent in psychosis?

Clarke, (2001) notes:

Psychosis and spirituality both inhabit the space where reason breaks down, and mystery takes over. For me as a psychotherapist working with people with psychosis, this encounter poses questions: questions such as; “Why is religious/spiritual preoccupation and subject matter so prominent in psychosis?” “How come they both share a sense of portentiousness and supernatural power, and where does this sense come from?”

Wilber’s (1980) suggestion, based upon his developmental model of consciousness, is that a ‘schizophrenic break’ represents a regression to a deeper, underlying psychological structure that was traumatised in infancy or early childhood[5]. This regressive episode can be precipitated by the natural emergence of the ‘subtle’[6] that can begin to happen in late adolescence. If the inter-penetrations of the subtle do not have a solid anchorage in a ‘centaur’ level[7], they meet with a tenuously anchored or false self.

The subtle floods the false self, forces regression to lower structures with simultaneous invasion from higher realms

Wilber (1980) p157

Hence though both pre-egoic and trans-egoic experiences are engendered – this is essentially a pre-personal psychosis. Should those subtle inter-penetrations meet a firmly established centaur, then the expressions of the experience may still be psychotic, but – in the absence of regression to earlier developmental ‘faultlines’ – this can be a potentially transpersonal episode.

Wilber also writes of the ‘true mystic path’ of progressive evolution of consciousness. He asserts that the mystic is exploring and mastering some of the same higher realms that overpower the schizophrenic but:

The mystic seeks progressive evolution. He trains for it. It takes most of a lifetime – with luck – to reach permanent, mature, transcendent and unity structures.

P.158

Initial assessment and referral

Meanwhile, back in a San-Fransico an overworked mental health professional is assessing a young Englishman who is experiencing a psychotic episode. His client has spoken of a one-off use of peyote[8] – also of ceasing to use alcohol completely for the last 4 weeks after having been a daily drinker since age 16. He’s living as a street musician; sharing a windowless box-room in a Broadway hotel with his musician girlfriend/travelling partner and another musician they have met. He is sleeping very little, forgetting to eat, experiencing multiple ‘synchronicities’, delusional ideation, hearing occasional (benign) voices, struggling with even simple daily decision-making, confused, occasionally fearful when overwhelmed with paranoid conspiracy theories. Other-times, however he is excited and enraptured by the unfolding complexities and inter-connectedness of a magical/mythical sub-text which he is beginning to discern underlying his daily (bohemian) reality.

There is no significant history of mental illness in the family. There has been no reference to physical, emotional or sexual abuse in childhood – the client appears to have had relatively stable family background and is actively socially engaged. Nor does he report any traumatic or highly distressing life-experiences such as bereavement or assault. He’s a psychology graduate – he also appears to be on a seekers path with an interest in mysticism and comparative religion. The client is strongly opposed to medication – he seems unlikely to comply if it were prescribed. He is not a danger to others – though he may be vulnerable to falling foul of the law.[9]

 

A)   The assessment clinician, remembering Karon & Vandenbos, (1970) research, offers the client CBT therapy[10]. Or:

B) the assessment clinician, having read of a Spiritual Emergency Network set-up the previous year by Stanislav and Christina Grof (1980), makes contact and is referred to an integrative therapist who incorporates a transpersonal perspective in her work

Scenario A:                        Cognitive Behavioural  Therapy

“There is now no disorder to which cognitive behaviour therapy has not been applied, including teaching psychotic clients to control their symptoms”

Scott & Dryden 1996            p174

Developed originally for the treatment of depression (Beck et al, 1979), CBT was thought to be ineffective with psychosis. Research evidence now shows that even previously unresponsive and medication-resistant psychotic symptoms can be modified (Kuipers et al, 1998)

The underlying theory of personality and motivation is predicated on an explanation of human experience as a product of the interaction of: physiology, cognition, behaviour  and emotion. The primary emphasis on breaking out of negative cycles of interaction has been via the cognitive and behavioural components of the matrix. This psychoeducational approach teaches the ABC model. Clients are encouraged to view their problematic scenarios in terms of Activating event, Belief about, or interpretation of, that event and Consequences: emotional leading, often, to behavioural responses to B, rather than A per se. Irrational/dysfunctional beliefs are identified and challenged on the basis of questioning for evidence.

The term CBT applies to a family of different models born from the above; they share at least 4 features in common: (Scott & Dryden, 1996 p164)

1) Therapy begins with an elaborate assessment and well-planned formulation. [11]

(See App. 2)

2) CBT provides training in skills that the client can use to handle life events more effectively – specifically, training the client to identify the B’s and to question their validity and usefulness.

3) CBT emphasises the use of these skills outside of the session – ‘homework tasks’

4) Therapy encourages the client to attribute improvement in mood/reduction of symptoms more to his own changed thinking habits and increased skillfulness than to the therapist’s endeavours. Psychometric tests and self-rating scales are frequently used and re-used to measure for and acknowledge improvement/progress.

CBT therapists believe that a change in symptoms follows a change in thinking (or cognitive  change) which is brought about by a variety of possible interventions, including the practice of new behaviours, analysis of faulty thinking patterns, and the teaching of more adaptive self-talk.

Formulation 1:

Formulation is a collaborative venture; collaboration is –particularly with psychotic clients – essential to the development of a working alliance.

I noted, in my role-played assessment (App.2) my relief upon hearing my assessor’s statement “we are only here to do what you want”

In thinking about the client’s goals from the clients position the therapist will make judgements about which are most healthy, most realistic, most achievable and most likely to meet the client’s overall needs. Goals and ways of assessing outcomes will often be up for negotiation during formulation. The therapist will also be watchful for recurring themes, which may indicate more deeply held beliefs about self and role in life (schemata)

Bases on the assessment (App.2) we reached the subsequent formulation: 

Goals: making good decisions, being more in control, being more reliable, understanding the problem, reducing anxiety and fear, improving sleep and appetite, coping with confusion and concentration. Reducing delusions/hallucinations

Predisposing factors: family and personal history, pre-morbidity personality type

Precipitating factors: peyote, stress, cannabis, sudden reduced alcohol, and soul mate connection

Maintaining factors: refusing medication, compromising close relationships, continued use of drugs, stress of travelling and living in new culture.

Symptoms: (-ve) feeling unreliable, not in control, confusion, poor concentration,                            hallucinations and delusions.

(+ve) fascinated interest, enlightenment potential

Ameliorating factors: music, exercise, talking (limited, can be counterproductive with girlfriend and ‘street people’), return to alcohol (not yet tried)

 

Implications for treatment:

Hall, 1999, describes four main areas of focus:

 

1.            Coping strategies:

Traditionally, therapeutic interventions would initially focus upon a reduction in the maintaining factors. Behavioural experiments would be devised to ‘boost’ ameliorating factors – particularly those, which served as distraction. [12]

 

2.            Goals: The aim is to generate hope by highlighting worthwhile or short-term goals that may be achieved despite continuing disabilities.  Anxiety reduction, combined with moving towards a greater sense of being in control, would be the most practical initial goals to focus upon.

 

3.             Modification of delusional beliefs

There is growing consensus that psychological approaches can be used to modify strongly held beliefs. The therapist might encourage the client to consider alternative interpretations for his or her delusional beliefs by setting up tests for validity, by asking for (concrete) evidence to back up those beliefs, or by pointing out contrary evidence.

I would have had difficulty in accepting a direct challenge to the subjective reality of my experiences.

One way around this may be to take out the positive elements of the experience (‘enlightenment potential’, spiritual awareness) and label them as positive goals for later exploration.  This leaves the ‘difficult’ aspects of the delusional experience more exposed to rational cognitive challenge.

 

4. Modifying dysfunctional assumptions

Clients with continuing psychotic symptoms may hold assumptions about his or her self, which lower their self-esteem. These dysfunctional assumptions may be associated with self-defeating patterns of thought and behaviour, which may be an important cause of the failure of coping strategies. To address these assumptions the therapist starts by trying to clarify their nature, perhaps by questioning about the origins or assumptions and how they affect the client’s life.          (Hall, 1999)

My own assessment revealed   ‘a need to be brave, self-confident, cope alone’ which may be compensatory for underlying doubts about these qualities in myself.

From this framework, it might also be hypothesised that my ‘need to identify spiritual truths’ in this late adolescence experience may be compensatory for my rejection, at the onset of adolescence, of my Roman Catholic religious conditioning.

Underlying but permeating each of the above treatment areas will be psycho-educational interventions designed to promote ‘insight’ and ‘compliance’ Insight, that is, into the ‘reality’ of the clients illness leading to compliance with the treatment protocol. These ‘therapist goals’ will most likely be deferred pending establishment of a strong working alliance.

Mis-diagnosis?

Had I been suffering from a pre-personal psychotic episode I would have perhaps been well served by the thoroughness of the CBT protocols. With insight and compliance I would have probably experienced a reduction in key symptoms. Had I been experiencing a ‘spiritual emergence’, though I may be coping better, I would have been short-changed by our encounter. Any chance of spiritual insight would have been sacrificed by my therapist’s subtle requirement that I have insight into the nature of my illness.

CBT’s heavy reliance upon ‘evidence’ is of value only within the limitations of objective, empirical world of causality. Any spiritual experience, insight, or belief framework held by the CBT therapist would, in all likelihood be withheld from the relationship in the interests of maintaining a professional, objective, scientific approach to treating the client’s problem.

What Evidence?

From the perspective of a developmental model of consciousness (Wilber, 1980), (Clarkson, 1975) to assess the truth/validity of events/propositions at one level by the standards of truth/validity of another level is to have made a ‘category error’.

In Clarkson’s 7 level model the CBT approach is firmly located in level 5: the rational/logical level.

Intimations from level 7 which:

“Can be characterised as being beyond yes and no, beyond causality, beyond either/or and beyond duality “                        (Clarkson, 1992. P211)

Are clearly outside the scope of CBT’s logico/rational quest for evidence.

Interestingly, Clarkson describes level 6 (the theoretical/metaphorical level) as the

“Space for narrative”                                     (Clarkson, 1992. P210)

We shall see later how a narrative approach to therapy can perhaps better ‘plug the gap’ between the factual truths of level 5 and the ‘wordless’ truths of level 7 (the transpersonal level proper)

Scenario B         the Transpersonal perspective

Transpersonal Psychology grew out of Humanistic Psychology which, in it’s earlier turn, took inspiration from the east in it’s emphases on ‘being in the here and now’, ‘going with the flow’ and focussing on psychological health rather than disorder and, at best, conformity.

“…to oversimplify the matter somewhat it is as if Freud supplied to us the sick half of psychology and we must now fill it out with the healthy half”                                                   (Maslow, 1968.p5)

Maslow, a founding father of the humanistic movement, discovered that some people whom he regarded as particularly healthy had what he called ‘peak experiences.’ Peak experiences were subsequently recognised as occurring in other cultures and times under other names and circumstances. It was recognised that various eastern philosophies, psychologies and religions described not just peak experiences but whole families of peak experiences and claimed, contrary to Maslow’s ‘self-transcenders’ for whom these experiences were usually spontaneous, to be able to induce them at will. (Tart, 1983) Transpersonal psychology grew out of interest in these peak experiences and other ‘altered states of consciousness’ – known as ASC’s.

It is from the transpersonal perspective of western psychology that a counselling psychologist can best understand the ‘less than substantial’ notion of self held by eastern psychology.

In a paper entitled ‘Western Analytical Philosophy and Transpersonal Epistemology” (Chinen, 1996) identifies the following five distinct concepts of truth:

Correspondence, coherence, pragmatic, metaphoric and presentational

And in conclusion asserts:

 

            “All the modes of truth are needed for an adequate understanding of the human condition: from the mundane to the sublime, childhood to                                     elderhood, and prepersonal to transpersonal…the question is not simply  whether transpersonal experiences are true or not. The real question is,                         true in what sense?”  

(in Scotton, B; Chinen,A; Battista,J. eds.1996.p.227)

  In ‘Assumptions of Transpersonal Psychotherapy’ Wittine (1996), in the same volume, offers five postulates to help to describe the core concepts of therapy informed by a transpersonal perspective.

            1) Transpersonal Psychotherapy is an approach to healing/growth that  addresses all levels of the spectrum of identity- Egoic, Existential, and                                     Transpersonal.

            2) Transpersonal Psychotherapy recognises the therapist’s unfolding  awareness of the Self and his or her spiritual worldview as central in                                     shaping the nature, process, and outcome of therapy.

            3) Transpersonal Psychotherapy is a process of awakening from a lesser to a  greater identity.

            4) Transpersonal Psychotherapy facilitates the process of awakening by enhancing inner awareness and intuition.

            5) In Transpersonal Psychotherapy the therapeutic relationship is a vehicle for the process of awakening in both client and therapist.

Assessment:

Lukoff (1985)[13] proposes five criteria by which a spiritual emergency may be identified:

1. Ecstatic Mood – the most consistent feature

2. Sense of newly gained knowledge

3. Perceptual alterations – hallucinations

4. Delusions with specific themes related to mythology – he identifies 8 major themes:

Death, rebirth, on a mission/journey, encounters with demons, cosmic conflict, magical powers, utopian dreams, and Divine union.

5. Absence of conceptual disorganisation – disrupted thought and speech patterns are more indicative of a schizophrenic psychosis than spiritual emergency.

 

Based on a survey of the outcome literature, Lukoff suggests four prognostic signs indicative of a positive outcome

1) Good pre-episode functioning

2) Acute onset of symptoms during a period of three months or less

3) Stressful precipitant to the psychotic episode

4) A positive exploratory attitude toward the experience.

He acknowledges that even using these criteria, it often remains difficult to distinguish spiritual emergencies from episodes of mental disorder and quotes Agosin (1991) who reminds us:

Both are an attempt at renewal, transformation, and healing (p.52).

A statement of Formulation:

You may be experiencing a breakthrough of insight and intuition from a higher/spiritual/transpersonal level of consciousness. This may well be a natural process of personal development but, without an adequate framework for understanding, it is not only difficult for you to make sense of these experiences – it can sometimes be frightening and disorientating. This is very likely a brief period of transition, but while your experiences continue to be somewhat chaotic, it will help to identify and avoid/or reduce exposure to those persons and situations which appear to accentuate those difficult symptoms. When your feeling of disorientation has subsided we can begin to work together towards making meaning from the experiences.

Or, “ You have been overwhelmed by a glimpse on non-dual reality; your belief in who you thought you were has been temporarily shattered.  We can collaborate in rebuilding an appropriate subjective reality for you. This will not necessarily require you to deny the truths of your recent or current experiences.

Implications for treatment:

Grof & Grof (1985) have summarised a holistic therapeutic approach into nine categories:

1)   Normalise – The very use of the term ‘spiritual emergency’ is a contribution to the normalisation. This step – vital in our secular, modernist society – may be less important in, for example, a Hindu or Buddhist culture –which accepts the concept of transcendental development.  Cortright, (1997) explains:

Education about spiritual emergency serves two primary functions. First it gives the person a cognitive grasp of the situation, a map of the territory he or she is traversing. Having a sense of the terrain and knowing others have travelled these regions provides considerable relief in itself. Second, it changes the person’s relationship to the experience. When the person (and those around him or her) shifts into seeing what is occurring as positive and helpful rather than bad and sick, this changes the person’s way of relating to the experience. To know that this process is healing and growthful permits the person to turn and face the inner flow of experiences, to welcome them rather than turning away or trying to suppress them  (p. 173)

My mentor ‘normalised’ for me when he told me that he and many others he knew had been through a similar experience to the one I was having.

2)            Create a therapeutic container: Perry (1998) the founder of a residential treatment centre for spiritual emergence[14] suggests that when working with a client whose psyche is activated the therapist needs to empathise, to actively encourage and facilitate the process and to lovingly appreciate the qualities which are emerging in the process. Cortright (1997) adds:

Warmth and compassion combined with a degree of softness and gentleness are essential, for hardness, coldness, coldness, or insensitivity can be highly jarring to the delicate and refined perceptions of a person undergoing these consciousness changes.

In a series of (apparently!) chance meetings – in the café where our band would play, in the street and also at the airport as I checked in for my departure flight – my mentor displayed such qualities. He also had an instinct for the enduring facilitative intervention[15]

  C)   Help client to reduce environmental and interpersonal stimulation: In a similar way to the CBT therapist, the counselling psychologist will work in collaboration with the client to identify specific people and situations which accentuate the more difficult symptoms of the condition.

In my sudden return home I put the Atlantic Ocean between myself and my mysteriously telepathic fiddler friend and the chaos of San Francisco street-life. 

4)             Suggest the client temporarily discontinues spiritual practices  – this is particularly relevant, for example, in the intensive retreat situation where disciplined practice of exercises appear to have precipitated the crisis.

Determined, initially, to continue my headstands I became suspicious of their effect and discontinued the practice

5)            Use the therapy session to help ground the patient  – helping the client to be in the present; to focus away from disturbing mind-chatter.

6)             Suggest the client eat a diet of “heavy” foods and avoid fasting.

At the height of my ‘episode’ I was rarely eating. My sudden return to the parental home was a return to regular meals, cakes and pastries! 

7)            Encourage the client to become involved in simple, grounding, calming activities ­

Upon my return I spent up to ten hours a day for almost two weeks painstakingly tuning up – with a metal file – an old accordion I had bought in San Francisco.  The accordion was a very meaningful artefact in my story of what was happening to me. Tuning the accordion was a powerful metaphor for tuning myself back into consensual reality.

More recently, in working with a psychotic client, I have persuaded the institution in which he is incarcerated to allow him juggling bags in his room.

8)             Encourage the client to draw, paint, mold clay, make music, journal, write poetry, dance – creative practices/modalitites for further expression in symbol and metaphor of that which eludes verbal representation.

As well as absorbing myself in learning numerous Irish jigs and reels on the penny whistle, I began[16] to write a song that condensed some of the ‘journey’ imagery of the episode. (See Appendix 1 – tape enclosed)

9)             Evaluate for medication – Perry, arguing against the use of medication, suggest medication ‘mutes’ the psychic energy required to keep the process moving forward.  Small doses of anti-psychotic medication could perhaps help in the case of the more intense episode, to lower anxiety levels such that therapy is facilitated. Medication may make the difference between a client being seen as an in patient or an outpatient. The context is important – should the episode take place within the confines of a spiritual community, then it is more likely that the community could ‘hold’ a disturbed client.

My own theory for ‘self-medication’ was that if my experiences ever became too scary and out of control then I would ‘switch the process off’ with a heavy dose of alcohol. It was after I had engaged in this strategy and discovered no ameliorative effect that I decided on a sudden retreat back home.

As the client regains more stability a narrative approach to therapy can support the client in the crucial task of making meaning of the experiences. The patient is in search of a new story, or of reconnecting with her old one. . . The story needed to be doctored, not her. (pp. 17-18).

(Hillman,1983)

Lukoff (2002) describes three phases:

Phase 1             Telling the story of the spiritual emergency

A traditional mental health approach may be interested in the causes and exacerbants of delusion – but not the contents! To engage may to be to risk reinforcing the clients’ ‘delusional system’ For this approach, however:

“Putting such experiences into words is usually the first step in developing a life-affirming personal mythology that integrates the spiritual dimensions of the crisis”                                                                                                            Lukoff, 2002

This is the first step towards understanding the message of the episode

Phase2                Tracing it’s symbolic/spiritual heritage

Lukoff quotes two Jungians to illustrate the importance of this phase:

Eliade (1960) suggests that it requires:

…the general and the universal symbols [to] awaken individual experience and transmute it into a spiritual act, into metaphysical comprehension of the world. (p. 213).

Whilst Beebe (1982) states:

Minimally, the experience of illness is a call to the Symbolic Quest. Psychotic illness introduces the individual to themes, conflicts, and resolutions that may be pursued through the entire religious, spiritual, philosophical and artistic history of humanity. This is perhaps enough for an event to achieve  (p. 252).

Even modern, future oriented media imagery with mythic themes: Star Wars, Star Trek – may provide useful structures for a client working to reintegrate an intensely personal experience into a collective archetypal story.

Phase 3   Creating a new personal mythology incorporating the spiritual emergency

In this step the client ‘re-personalises’ the experience by incorporating the messages of the episode, via the collective framework, into a personal myth to assist in shaping expectations and to guide future decisions. The personal myth will address and inform such central issues as identity, direction and purpose. This step will be best facilitated by the tentative yet enthusiastic collaboration of a therapist who is comfortably familiar with a broad variety of mythological/spiritual themes and frameworks.

Mis-diagnosis?

Owing to the ambiguity of the presenting issue, there remains the possibility that the episode was not best described as a spiritual emergency. A therapist alert to a transpersonal approach to spiritual emergency may also be aware of the recovery model approach to mental illness: a bio/psycho/social/spiritual perspective which, drawing on the success of the 12 step programme with addiction, encourages clients towards:

 1. Accepting having a chronic, incurable disorder, that is a permanent part of them, without guilt or shame, without fault or blame.

2. Avoiding complications of the condition

3. Participating in an ongoing support system both as a recipient and a provider.

4. Changing many aspects of their lives including emotions, interpersonal relationships, and spirituality both to accommodate their disorder and grow through overcoming it.

Ragins, 1997

Conclusion:

I shall end with Ragins eloquent description of this radical reframing. The recovery concept can apply to both kinds of crises: ‘pre’ and ‘trans’. For the latter, one might read ‘spiritual emergency’ for ‘mental illness’ and ‘mortality’ for ‘incurable illness’!

For severe mental illness it may seem almost dishonest to talk about recovery. After all, the conditions are likely to persist, in at least some form, indefinitely.  How can someone recover from an incurable illness? The way out of this dilemma is by realising that, whereas the illness is the object of curative treatment efforts, it is the persons themselves who are the objects of recovery efforts.

References:

Agosin, T. (1992). Psychosis, dreams and mysticism in the clinical domain. In F. Halligan & J. Shea (Eds.), The fires of desire. New York: Crossroad.

B.P.S,(2ooo) Division of Clinical Psychology report Recent advances in understanding mental illness and psychotic experiences   www

Beebe, D. (1982). Notes on psychosis. Spring, 233-252.

Chadwick, Peter (1992) Borderline . A Study of Paranoia and Delusional Thinking. Routledge: London.

Clarkson, P (1975) Seven Level Model. Paper delivered at Pretoria University Nov 1975

Clarkson, P (1992)  The Therapeutic relationship   London: Whurr

 Coleman,R.(1999). Recovery: An alien concept?. Handsell Publishing.Oxford:Oxford University Press.

Cortright,B. (1997) Psychotherapy and spirit: Theory and Practice in Transpersonal Psychotherapy New York: University of New York Press

Eliade, M. (1960). Myths, dreams, and mysteries. New York: Harper & Row.

Grof, S, (1985)  Beyond the Brain: Birth, Death and Transcendence in Psychotherapy.  New York: State University of New York p.396)

Gunderson,J.G.,Frank,A.F.,Katz,H.M.,Vannicelli,M.L.,Frosch,J.P. &

Knapp, P.H.(1984).Effects of psychotherapy in schizophrenia.II:

Comparative outcome of two forms of treatment. Schizophrenia

Bulletin,10, 564–598.

Hall,M. (1999) Schizophrenia.co.uk http://www.schizophrenia.co.uk/background/cognitive_behavioural_therapy/

Hillman, J. (1983). Healing fiction. New York: Station Hill Press.

Karon,B.P. & Vandenbos,G.R.(1970).Experience, medication and the effectiveness of psychotherapy with schizophrenics.

               British Journal of Psychiatry, 116 (533), 427–428.

Lukoff, D. (1985). The diagnosis of mystical experiences with psychotic features. Journal of Transpersonal Psychology, 17(2), 155-181.

Karon,B.P. & Vandenbos,G.R.(1970).Experience, medication  and

the effectiveness of psychotherapy with schizophrenics.

British Journal of Psychiatry, 116 (533), 427–428.

Kuipers E, Fowler D, Garety P, et al.(1998) London-East Anglia randomised controlled trial of cognitive-behavioural therapy for psychosis. III: Follow-up and economic evaluation at 18 months. Br J Psychiatry  1998 Jul;173:61-8

Maslow,A.H (1968) Towards a psychology of being   Princeton, NJ: Van Nostrand

National Health Service Executive (1996). NHS Psychotherapy

Services in England Hospital and Community Psychiatry, 41, 1203–1211.

London: Department of Health.

Perry, J. (1998) Trials of the Visionary Mind : Spiritual Emergency and the Renewal Process (Suny Series in Transpersonal and Humanistic Psychology) New York: New York Press

Ragins, M. (1997) Recovery: Changing From A Medical Model To A Psychosocial Rehabilitation Mode in The Journal vol.5 issue 3 California: NAMI

Romme, M.A.J.& Escher, A.(1989).Hearing voices. Schizophrenia Bulletin. 15: 209–216. Oxford:Oxford University Press.

Russell, R. (1994) Do you have a Spiritual Disorder? The Psychologist,  7(7) p.384

Scott,M.J & Dryden,W.(1996) The Cognitive-Behavioural Paradigm – in Woolfe, R. & Dryden,W. (eds) (1996) The Handbook of Counselling Psychology London: Sage

 Scotton,B; Chinen,A; Battista,J. eds.1996. Textbook of Transpersonal Psychiatry and Psychology New York: Basic Books

 Tart,C.(1983a) States of Consciousness. El Cerrito,CA: Psychological Processes.

Walsh, R & Vaughn, F (2000) The art of transcendence: An introduction to common elements in transpersonal practices, Transpersonal Psychology  Review   vol.4, no.2

Wilber 1996, in Scotton,B; Chinen,A; Battista,J,1996,p128 Textbook of Transpersonal Psychiatry and Psychology New York: Basic Books

 

 

 

 



[1] More accurately, I was offered a dilemma which I declined!

[2] The Buddhist term kalyamitra – or spiritual friend – is a good description of this man’s support.

[3] About 4yrs later, at the end of a ten-day brown rice diet – camping in solitude in the lake district – I experienced euphoria and grandiosity similar in nature to feelings I recalled from the psychotic episode. These experiences evaporated rapidly when I returned to my normal eating patterns.

[4] In Civilisation and It’s Discontents Freud (1930)  speaks of his reaction to a letter received from the poet Romain Rolland -who had become a student of the  Indian sage Sri Ramakrishna. In it Rolland described a feeling of something ‘limitless and unbounded’ which he saw as ‘the physiological basis of much of the wisdom and mysticism’. Freud, puzzled with no similar referrent of experience, labeled this feeling ‘oceanic’ and suggested, as its origin, a feeling of infantile helplessness which he saw as the source of religious feelings.

[5] Pre-egoic

[6] Trans-Egoic -Wilber’s collective term for the transpersonal realms which develop after the Centaur level

[7] Egoic –  Centaur is the name given to the level of consciousness development at which there the ego identifies with a fully integrated bodymind.

[8] A cactus with psychedelic properties used by the Yaqui Indians in Mexico in sacred ceremony and ritual

[9] See Appendix 1 for a fuller description of presenting issues.

[10] I’m aware that a combination of medication and CBT was perhaps more likely. For want of words I prefer not to explore the medication option. Dr Rufus May, in the BPS briefing document,offers poignant  reflections about medication from his personal experience of being diagnosed and treated as schizophrenic.

[11] Space does not allow for this elaboration here. Instead, I have appended an assessment dialogue which took place between my supervisor – A clinical psychologist working for a mental health team – and myself speaking from memory of the psychotic episode

[12] For example, exercise: if jogging also serves as a private place for delusional rumination, then choose tennis where  the demand for concentration  precludes such preoccupation.

[13]  Further acknowledgements to Lukoff for his excellent web-based tutorial on spiritual emergence http://www.internetguides.com/blackboard/lessons/lesson1.html

[14] Diabysis centre – SanFransisco

[15] “it’s like an elevator – you go up and up but when you wanna stop you can just press the button” and

“if you fall, no matter how far down, there’s  always a safety net”

Both very reassuring  at times when I was feeling anxious about my ability to return to ‘normality’. At our final chance  meeting in an airport departure lounge he offered a cautionary  injunction against the possibility of me being a danger to others – ostensibly sitting on his right hand he said:

“you know, if you’re ever suspicious of or frustrated with anyone and you feel angry, always remain seated on the right hand of the father” Memorable all the more for having been wrapped in religious imagery.

[16] Not completed until some years after the episode

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