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to. Even then, there was at least a six-second delay before she replied, as if she was slowly processing what had been said. She was on quite heavy medication. The therapist to whom I assigned Linda's case quickly established that Linda's wish was to be able to be more of a mother to Molly. Instead, she spent most of her time alone, worrying about her shortcomings and listening to the voices, but unable to motivate herself to get up and do anything different.

The therapist suggested that Linda set an alarm clock for 8am and put it across the other side of the room from her bed, so that she would have to get out of bed to turn it off. This Linda agreed to do. Once up, she was able to help her mother prepare Molly for school and make decisions about what Molly would wear or take in her packed lunched. Quite quickly she got into the routine of getting up early, making the packed lunch, taking Molly to school and collecting her as well.

Taking back responsibility

Over a six-month period, she attended sessions with the human givens therapist (she abandoned the cognitive therapy) and also our workshops that show how to build social networks, starting with the importance of skills such as small talk and progressing through to the need for employable skills to gain entry to the world of work.

Gradually, Linda established structure to her life. She responded to the suggestion that she might try a hobby to fill time constructively during the day, and started knitting. She soon decided that was unsatisfying and not what she wanted to spend her time doing, but in the process had become clearer about what she did want to do. She wanted to be able to take back full responsibility for Molly. She started taking driving lessons. On request, the council provided her with a home of her own for herself and Molly, and she busied herself with decorating it. The voices began to disappear, as she was too busy to hear them, and she was spending less and less time with her overly directive mother.

At the centre, we saw that the emotion had come back into her face. She would smile, show empathy and respond instantly to questions. Although we had never discussed her medication with her, she told us she had been taking six different anti-psychotic and antidepressant drugs, and she had now reduced down to one. She said to us, in relief, "I feel like I've woken up."

Linda's psychiatrist was so struck by the change in her that he started to refer us more clients, telling them that medication couldn't solve everything!

The mental health continuum

Hartlepool Mind has the philosophy that all mental wellbeing exists on a continuum, from good mental health to ill mental health. So everything from stress to psychosis is on the same continuum, which is fluid. Everyone moves up or down, according to what is happening in their lives at the time and how equipped they are to cope with it.

Diagnoses of psychosis are of little value because someone who is diagnosed as manic depressive at one point is quite likely to be diagnosed as schizophrenic at another. It is far more helpful to work to normalise all human experience and support people through the dips. Tom McAlpine, a mental health specialist from Moodswings Network, based in Manchester, has been vital in assisting Hartlepool Mind in working with this philosophy.

Reality processed through the dreaming brain

The human givens idea that psychosis is reality processed through the dreaming brain also makes a lot of sense to me and can be helpful to use in explanation when talking to people who are having experiences that they realise are out of 'sync' with those of people around them. One young woman named Sian described how, during a manic period, she had been watching a science fiction drama on television and became obsessed with the possibilities of time travel. She started talking excitedly about it to friends and family.

"Part of me could see that people weren't as excited about the idea as I was and that what I was saying didn't make any sense to them. That part of me could see that I was being over the top and yet I just couldn't stop myself," she said. She felt comforted by the possibility that, when susceptible individuals are highly over-stressed, dreaming 'reality' can leak into waking reality.

Just as in a dream we sometimes realise that something we are doing is odd or shouldn't be possible, yet can't help but carry on regardless, so, in an overwrought state, the same experience can occur while awake. By discussing ways that she could lower her stress and thus reduce such occurrences, she ceased to feel so out of control and frightened.

Retreating into the imagination

When people experience ongoing emotionally painful or fear-inducing events that they have no control over, they often retreat into their imagin-
ations to protect themselves. It makes sense to think that a pathological amount of such daydreaming (a REM state trance, just as dreaming is) could tip people into psychosis, if their emotional needs are not being met, as a counterbalance.

Nathan, a man in his late 20s, was brought to see me while he was still an inpatient at University Hospital in Hartlepool. (The staff often bring us patients, so that we can become acquainted with them before discharge, when our role is to help them settle back into the community.) Nathan shook constantly and was clearly extremely stressed. He had started to believe that people might be in his home or were coming to look for him, and gradually became able to 'see' these imagined people. This experience disturbed him very much but he hadn't told the nurses, as his parents, with whom he still lived, were putting him under pressure to make a swift recovery and return to work. He was also distressed by certain bodily changes, such as heavy sweating and having a metallic taste in his mouth. He had started to wonder if 'they' were poisoning his food. I discovered that he had debts that he couldn't pay off. He felt pressured by his parents to make something of himself and to do well at an office job he disliked.

Nathan was seeing a cognitive therapist, who was working to help him change negative thoughts and attitudes. It seemed to me, however, that what
he needed most were coping skills and social connections in his life and, most immediately, to be able to make sense of the strange physical experiences he was having. During our session, he was quite clearly switching in and out of psychosis — he would frequently appear vacant and then suddenly 'come back' to us and begin talking again. I asked him if he was OK or if something else was happening, and he tentatively revealed that he thought he could see things during the night, that people were maybe coming to get him. I asked about his hearing and he looked surprised and said, 'I think I can hear people talking about me'.

When he was rational, I took the chance to tell him how stress affects the body — for instance, that metabolic changes may make the body overheat and sweat, and the rise in cortisol production may create a metallic taste in the mouth. It also wasn't so surprising that he had started to hallucinate pursuers, as his overriding concern was being pursued for debts he couldn't pay. When these experiences were normalised in this way, he ceased to fear them.

Meeting needs and reducing pressures

We talked about the need to reduce his stress and how this could be achieved. He said he wished he could have a small flat of his own in a pleasant area, away from his overbearing parents, where he could go to a gym and start to mix with people socially again. He agreed, at my suggestion, to tell nursing staff and family about his hallucinations and concerns, so that he no longer felt pressured to try to feign wellness and return to work. We also arranged an appointment for him with the local Citizens Advice Bureau, so that they could help work out how to manage his debts.

The project team found Nathan a flat with warden-controlled access. Four months down the line, Nathan is managing for himself fairly well. By setting about meeting his needs and reducing the pressures that were causing him to flip into psychosis, we were able to keep him connected to the real world. The hallucinations disappeared very quickly. Without such intervention, they might well have intensified and left Nathan disabled for a lifetime.

Working with people who self harm

The practical needs-led approach we have adopted has given me more confidence in working with people who self harm. For very many people who self harm, emotional distress is a physical experience, and they may cut to prove to themselves that they feel nothing or to bring themselves back from a dissociated state. It is instinctive to want to encourage people to stop injuring themselves but usually counter-productive.

When 22-year-old Chrissie came to the centre, she had been cutting herself for three years. It was difficult to build rapport with Chrissie. She found it hard to articulate her emotions or, more basically, even to distinguish between emotions, both in herself and others. To her, emotions felt either good or bad, and that was very limiting.

I at no time asked her to stop harming herself, telling her I respected that that was her private world. One of the centre workers took Chrissie to a cafe where they sat and observed the expressions on customers' faces. If any people didn't look happy, Chrissie routinely catastrophised, imagining that they felt suicidal and might be thinking of going home to kill themselves.

So we agreed that she needed to develop an understanding that emotions could be subtle, and how to identify them so that she could relate more easily to others. We encouraged her to mix more with others, at adult education courses, skills development workshops and, finally, by volunteering at the local hospital, so that she had more opportunities to engage with and talk to people and see whether her reading of situations was accurate or needed adjustment.

After four months, with the ongoing help of her recovery support worker, Chrissie had considerably enhanced her social skills and had developed, and continues to maintain, her own social network, which enables her needs to be met. She has not cut herself for some time.

Mood Management

Many of our clients join our mood management programme, which helps people to identify the symptoms that may precede a lurch into mania or a dip into depression. These vary from individual to individual, and may be very small. For instance, overly dry or greasy hair or dry or prickling skin or racing thoughts or not wanting to sleep may be a first sign of incipient mania for some.

Identifying the tell-tale signs enables a person to nip the problem in the bud to resist the urge to go partying or to drink or to start a relationship with a person met at the bus stop and to look at what is actually distressing them (such as a too-pressured work schedule or a relationship difficulty), and do something to redress the balance, such as taking time out or talking with the partner or a friend.Similarly, a first sign of oncoming depression might be a desire to withdraw from company or to stay late in bed.

A strategy to deal with it might include deliberately socialising and keeping to scheduled activities and ensuring sufficient but not excess sleep. In

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© Human Givens Publishing Limited and Iain Caldwell (2004)

References

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This article first appeared in Volume 11, No, 1 (2004) of the Human Givens journal.

IAIN CALDWELL is the mental health support network co-ordinator of Hartlepool Mind. He originally studied psychology at Liverpool John Moores University. He has an assertive outreach nursing certificate from Teeside University and a post-graduate certificate of education from Sunderland University. He has also studied various therapy skills, gaining a certificate in hypnosis and the Human Givens Diploma. Iain has worked variously in outreach, supporting people discharged from a special hospital, and as an advocate and mentor.

> More information can be found in the following books, both by Joe Griffin and Ivan Tyrrell

Dreaming Reality: How dreaming keeps us sane or can drive us mad

Human Givens: A new approach to emotional health and clear thinking

> You can find out more about psychosis and the new thinking on its causes at the following MindFields College events:

Understanding the mental health continuum Seminar

Psychosis: and positive strategies for Recovery Workshop

Return to top

> More information can be found in the following books, both by Joe Griffin and Ivan Tyrrell

Dreaming Reality: How dreaming keeps us sane or can drive us mad

Human Givens: A new approach to emotional health and clear thinking

> You can find out more about psychosis and the new thinking on its causes at the following MindFields College events:

Understanding the mental health continuum Seminar

Psychosis: and positive strategies for Recovery Workshop

Return to top