Negative Symptoms

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• Negative Symptoms
• A Critical Look and a Motivational Approach
• Isabel Clarke
• Consultant Clinical Psychologist
• AMH Woodhaven

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AIMS

• Putting so called negative symptoms into context
  by looking at Psychosis holistically and from an
  experience point of view.
• Negative Symptoms. Critical look at the concept.
• Introduce the MI approach an example of a staff
  training intervention.
• Common Core Philosophy an approach to the
  medical model problem

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Psychosis and Getting Life Back on Track

• The role of the psychologist in helping the
  system to look beyond diagnosis
• Symptoms versus experience
• Take the person and their experience seriously
  goes with working collaboratively what would
  this mean?
• This means a whole system approach working with
  the institution as well as the individual
• Engagement with the system what helps and what
  gets in the way?

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Symptoms? What Symptoms? A critical look a the
concept.

• The word assumes an illness conceptualisation
• The medical model as metaphor one possible
  metaphor among many
• Language and power issues..
• Implications for the individual about the choice
  of metaphor a passive patient or a human being
  coping with their life as they experience it
• ..in the face of the constant invalidation

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Taking Experience Seriously in Psychosis

• What is the nature of experience in psychosis?
  How does this experience impact on the
  individual?
• Normalising the difference as well as the
  continuity
• Sensitivity and openness to anomalous experience
  continuum with normality Gordon Claridges
  Schizotypy research.
• Understanding the role of emotion where
  expression of emotion is not straightforward
  the feeling is real even if the story is
  suspect.

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The Holistic Revolution in Psychosis

• Recognising the role of arousal (Hemsley,
  Morrison)
• Importance of emotion (Gumley Schwannauer
  Chadwick)
• Attachment and interpersonal issues ()
• Self acceptance and compassion ( Gilbert)Self
  esteem, (Harder).
• Loss and Trauma
• The Recovery Approach.
• All these lead to a blurring of diagnosis

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The Epidemiological and Cross Cultural
Perspectives

• Richard Warner Recovery from Schizophrenia.
• WHO epidemiological studies
• Overrepresentation of people from other cultures
  in the Mental Health Services here what is that
  about?
• Studies of overlap with spiritual experience or
  where acceptance of anomalous experience leads to
  better outcome
• Emmanuelle Peters,
• Mike Jackson.
• Caroline Brett.

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Evidence for a new normalisation

• Schizotypy a dimension of experience Gordon
  Claridge.
• Mike Jacksons research on the overlap between
  psychotic and spiritual experience.
• Emmanuelle Peters research on New Religious
  Movements.
• Caroline Bretts research having a context for
  anomalous experiences makes the difference
  between whether they become diagnosable mental
  health difficulties
• and whether the anomalies/symptoms are short
  lived or persist.

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A holistic, cross diagnostic approach to
symptoms shaded area anomalous
experience/symptoms are more accessible.
Level of Arousal
Ordinary, alert, concentrated, state of arousal.
Low arousal hypnagogic attention drifting etc.
High Arousal - stress
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DIALECTICAL BEHAVIOUR THERAPY Linehans STATES
OF MIND applied to PSYCHOSIS

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Questions and Theories about Negative Symptoms

• What are they?
• Orthodoxy says they are they a core form of the
  illness
• Are they distinct from depression?
• A product of medication side effects?
• of environmental deprivation?
• Dysphoria about life change?
• Of loss of social position and hoped for life?

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Negative symptoms cont.

• Are they a protective response to the experience
  of positive symptoms?
• A product of positive symptoms as these interfere
  with engagement with normal life?
• Cognitive Theories
• Theory of mind deficit argument (Pickup Firth
  2001)
• Cognitive deficit arguments. E.g. Putnam Harvey.

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Medication side effects

• Dopamine is involved in the reward system of the
  brain
• It is particularly associated with anticipation
  of reward therefore motivation
• Antipsychotic medication reduces dopamine
  activity and therefore affects motivation
• Arias-Carrion, O. Peoppel, E. (2007) Dompamine,
  Learning and Reward Seeking Behaviour. Acta
  Neurologicae Experimentalis 67 481-488.
• Some antidepressant and antipsychotic medication
  affects sexual response.

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Sensitivity Argument(Watkins, J. (1996) Living
with Schizophrenia. An holistic approach to
understanding, preventing and recovering from
negative symptoms.

• Psychosis high on the schizotypy spectrum and
  so more sensitive and open.
• Leading to the need to regulate stimulation.
• This can lead into an avoidance cycle social
  isolation and withdrawal
• Psychotic reality takes over.
• Psychotic reality can be more attractive than a
  stimatized and marginalized role in the shared
  world

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Therapeutic Approaches

• 1. To Sensitivity
• Validate the sense of vulnerability
• Negotiate graduated exposure to more social
  interaction.
• 2. To the attraction/escape value of the
  alternative reality.
• Validate the attraction take a motivational
  approach
• Encouragement to find and pursue valued roles in
  the shared world with support

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Therapeutic Approaches cont.

• 3. To loss of direction in life
• Both unrealistic hope and despair paralyse
• acknowledge loss of hoped for future
• emphasise immediate, small scale achievement
• foster medium term achievable goals
• stay with the individuals vision and choice.
  working with strengths and interests
• Individual goal setting work. negotiate valued
  goals and monitor their progress a therapeutic
  approach for the staff group and a nice research
  project

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Introducing this model of working to the Staff
GroupUsing Motivational Interviewing.

• MI principles 1. EXPRESS EMPATHY
• Acceptance facilitates change
• skilful reflective listening is fundamental
• ambivalence is normal.
• Addiction Approach/avoidance
• Psychosis Hope/Despair.
• 2. DEVELOP DISCREPANCY
• Awareness of consequences is important
• a discrepancy between present behaviour and
  important goals will motivate change
• the client should present the argument for
  change.

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3. AVOID ARGUMENTATION

• Arguments are counterproductive
• defending breeds defensiveness
• resistence is a signal to change strategies
• labelling is unnecessary - get away from illness
  language and arguments about diagnosis
• SUPPORT SELF EFFICACY AND SELF ESTEEM
• Belief in the possibility of change is an
  important motivator.
• Every communication should increase self
  efficacy/self esteem.

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Common Core Philosophy(This applies across
diagnoses).

• Hope
• Working with strengths.
• Normalisation.
• Common humanity, common vulnerability.
• Collaboration.
• Accepting reality.
• Idea of Balance and Finding a Middle Way.
• Proactive, collaborative response to risk and
  challenge.

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Hope.

• CBT. Cognition and behaviour can change. You can
  take responsibility and choose. Not fatalistic.
• Central to Recovery.
• DBT the life worth living.

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Working with strengths.All look at the whole
person, not the pathology.

• CBT. Behavioural approach to challenging
  behaviour focus on behaviour to increase what
  the person can do as opposed to what they do
  wrong.
• Recovery regaining or developing valued roles.
• DBT. Encouraging mastery.

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Normalisation.

• CBT. We all have dysfunctional thinking patterns
  and challenging behaviours sometimes. We can
  apply the approach to ourselves.
• Recovery. Building a life outside the services
  employment focus.
• DBT. Biopsychosocial model applies to some degree
  to everyone.

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Common humanity, common vulnerability.

• CBT. Therapists monitor the effect of
  challenging behaviour on their own arousal
  systems and thought patterns, and sidestep
  reproducing the pattern or responding from the
  raised state of arousal.
• Recovery. Trainers devise their own WRAP plans.
  Encouragement of employment of those who have
  recovered in the services (experts by
  experience).
• DBT. Therapists note own therapy intefering
  behaviours, dialectical dilemmas and emotion mind.

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Collaboration.

• CBT at the heart of the approach goals of
  therapy are arrived at collaboratively.
• Recovery service user sets the agenda.
• DBT. Client must agree to work on reducing self
  harm as a first priority, but the life worth
  living is their own vision.

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Accepting reality

• CBT.Person has to accept that there is a problem
  for the problem list. They have to accept that
  they have a role in dealing with it to form a
  collaborative alliance.
• Recovery. The concept of the turning point means
  the point at which the individual recognises
  whatever limitations are imposed by their
  problems, and accepts what has happened in the
  past this makes taking ownership of their
  future possible.
• DBT. Acceptance is a core concept.

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Self Monitoring

• CBT Thought Diaries.
• Recovery WRAP.Identify wellness, and then
  triggers and early warning signs for relapse.
  Relapse is a normal part of recovery.
• DBT Diary cards.Chain analysis.

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Response to Risk and challenge.

• CBT. Collaborative risk management is the most
  effective. Specifying behaviours to increase and
  reinforcing them is the most efficient way to
  decrease challenging behaviours.
• Recovery. WRAP individual responsibility for
  maintaining wellness and specifying what should
  happen in case of breakdown.
• DBT. Skills training, featuring mindfulness, to
  master action urges.

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Idea of Balance and Finding a Middle Way

• CBT. Continuum work. Dysfunctional thinking is
  usually extreme CBT works towards finding the
  middle ground.
• Recovery. Balance between learning to live with
  symptoms and a relapsing condition, and making
  the most of life.
• DBT. Always looking for the dialectic, and for
  the wisdom in both poles while seeking a way
  through. There is no one right way the process
  carries on.
• Behavioural approach to challenging behaviour
  balancing the obvious, behaviours to decrease
  with emphasis on behaviours to increase.

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Unique features

• CBT. Individual formulation of difficulties.
• Recovery. Service users, not professionals, in
  charge.
• DBT. Skills training and mindfulness.
• However the similarities are more striking and
  numerous than the differences.

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Implications for staff role.

• Staff need to hold hope and vision for the
  individual even when they cannot yet see it.
• Staff need to concentrate their efforts on
  identifying and working with the persons
  strengths and interests.
• Staff need to see the person as they might fit
  into society to help them maximise their
  prospects. They need to listen to the person and
  take seriously what they say.
• Staff need to be aware of and manage their own
  emotional reactions.
• Staff need to develop their skill in working
  collaboratively.
• Staff have a vital role in enabling the person to
  accept what has happened and its consequences,
  and take responsibility for continuing problems.
• Staff must keep in mind the need to balance
  working with strengths with realistic support
  with problems.
• In managing risk, staff need to seek the full
  collaboration of the service user.

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Principles for working with staff

• Respect their professionalism take every
  opportunity to raise their morale and self esteem
• It is your role to be the expert you do have
  something to offer.
• Offer it in a spirit of collaboration
• The Medical Model problem I go for both and

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Contact details, References and Web address

• Isabel.Clarke_at_hantspt-sw.nhs.uk
• AMH Woodhaven, Calmore, Totton SO40 2TA.
• Clarke, I. Wilson, H.Eds. (2008) Cognitive
  Behaviour Therapy for Acute Inpatient Mental
  Health Units working with clients, staff and the
  milieu. London Routledge.
• Clarke, I. ( 2008) Madness, Mystery and the
  Survival of God. Winchester'O'Books.
• Clarke, I. (Ed.) (2001) Psychosis and
  Spirituality exploring the new frontier.
  Chichester Wiley
• Durrant, C., Clarke, I., Tolland, A. Wilson, H.
  (2007) Designing a CBT Service for an Acute
  In-patient Setting A pilot evaluation study.
  Clinical Psychology and Psychotherapy. 14,
  117-125.
• www.isabelclarke.org