1. Mindfulness for Distressing
Psychosis
Professor Paul Chadwick
Institute of Psychiatry
King’s College, London

2. Mindfulness
• Origins in Buddhism
• Mindfulness-based intervention is psychological
practice that sit outside Buddhism
• Not a set of beliefs (not an ‘ism’) – nothing that
you are asked to believe (empirical)
• Practice of easing distress/suffering by learning
to relate to experience in a different way
• Swept physical and health care worldwide: (i)
100s of millions in research grants, (ii) 700
journal publications in one year!

3. Mindfulness for psychosis
• And yet…mindfulness for psychosis very
slow to develop
• UK & USA: very little research and clinical
practice
• Very pleased to collaborate with staff at
Serralta Rehabilitation Unit & University of
Balearic Islands: Ovidio Fernàndez, Antoni
Mayol, Enric Munar, Josep Luís

4. Why are things so slow?
• Widely held perception that meditation is
harmful for people either vulnerable to,
or currently experiencing, psychosis
• Small literature on meditation &
psychosis – not evidence-based
• Parallels between subjective reports of
meditation states and psychosis
• General reluctance to bring
developments to people with psychosis

5. Adapting mindfulness
1. Not ‘should we offer Mindfulness’, Yes or No
2. “How can we adapt mindfulness practice to be
safe, acceptable and therapeutic for people
with psychosis”
3. Intention is to support clients to develop a new
relationship with distressing voices, thoughts,
images, feelings

6. The practice
• 10 minutes
• Avoid long silence: Guidance every 30-60 seconds
• Refer to psychotic experience during guidance
• Establish an anchor (body, breathing)
• When voice, thought etc in foreground – stay with it until
fades/passes. Not attempt to pull awareness away
• Rest awareness in breathing when not drawn by voices,
images etc.
• When get lost, reconnect with body & breath, and open
out again
• Combines focussed attention with open awareness

7. A model to guide the process

8. Fear of changing relationship
Omnipotence of voices (Chadwick & Birchwood)
• Bauer (1979): Voices are imbued with a
‘terrifying and compelling quality’ and individuals
feel ‘caught in their power’
• 80-90% of voices experienced as omnipotent
• Linked to depression
• If working therapeutically with distressing voices,
need to address omnipotence early on

9. Testing metacognitive Beliefs
• Metacognitive beliefs are fears about consequences of
changing relationship, letting go of coping
• Kathy: “Unless I react to my voice and images I will lose
contact with reality and my family altogether”
• Sue: “If I stop fighting the voices they will come back in a
new way, even stronger, more powerful, and I wouldn’t
know what to do”
• Mindfulness practice as a behavioural experiment
• Practice & Guided reflection after each practice aimed at
new metacognitive insights (John Teasdale)
• Sue: “When I can let go of fighting I feel calmer, more
peaceful, more in control”

10. What is mindfulness really?
• ‘What is Mindfulness, really…we see people who say,
“I’m being very Mindful”, and they’re doing something in
a very methodical, meticulous way. They’re taking in
each bit of food and they’re lifting, lifting, lifting; chewing,
chewing, chewing; swallowing, swallowing, swallowing…
but he may not be Mindful at all. He’s just doing it in a
very concentrated way; he’s concentrating on lifting, on
touching, on chewing, on swallowing. We confuse
Mindfulness with concentration…Mindfulness is always
combined with wisdom’
(Ajahn Sumedho, 1992, pp. 31-32)

11. Maximising learning
• Meditation practice and guided learning
equally important
• Actively supporting metacognitive insights
that alter relationship with psychotic
experience, and support self-acceptance
• Vital because clients with psychosis don’t
suddenly stop reacting: Chris 2 or 3 times
in 10 minutes

13. Mindfulness group format
• Two 10 minute practices
• Socratic questioning to support discovery
after each practice to maximize learning
• CD for home practice
• 3 minute breathing space (MBCT)
• Conceptualize as therapy, not skills class
• All groups follow Yalom’s (2005) Theory
and Practice of Group Psychotherapy.

14. Mindfulness groups: Study 1
• Clinical service, people with complex presentations, high
risk, long-standing unremitting psychosis
• 6-7 weekly sessions plus home practice
• N=11 (7m, 4w, mean age 33, 10 unemployed, 1 student)
• All distressing paranoia, 5 voices, 5 other halls (>2 yrs)
• Primary outcome CORE: significant pre-post
improvement
• Encouraging finding given literature – meditation harmful
[Behavior & Cog Psychoth, 33, 351-359]

15. Pilot Study 2
• N=22 (13w, 9m) all unemployed; mean age, 41,
duration of illness, 17.7 years
• All distressing voices > 2 yrs, 19/22 distressing
paranoia
• Therapy: twice a week for 5 weeks plus home
practice, followed by 5 weeks home practice
• Primary outcome CORE: Significant pre-post
improvement (n=15)
• Significant pre-post improvement in mindfulness
of distressing thoughts & images – but not
voices
[Behavior & Cog Psychoth, 37, 403-412]

16. Pilot 3: CBT + Mindfulness
• One 10 min practice plus CBT (Omnipotence &
beliefs about self)
• Unremitting distressing voices >2 years
(average 14 years)
• 64 began a group (26m), mean age 41: 88%
schizophrenia/SAD; 8% psychotic depression
• Primary outcome CORE: 54% showed reliable
clinical change at follow-up
(Dannahy et al, Journal of Behaviour Therapy &
Experimental Psychiatry, 2011)

17. Measuring Group Process
Rank order from most-least helpful statements
from Yalom relating to 8 therapeutic factors:
some examples
• Helping others and being important in their lives
(Altruism)
• Belonging to and being accepted by a group
(Group cohesion)
• Learning how to express my feelings (Catharsis)
• Learning to respond mindfully to thoughts,
feelings or voices (Guidance)

18. Group process: Findings
Mindfulness & Universality (Discovering that
others have similar problems) consistently
rated two most important
So group process is important, as well as
learning specific mindfulness skill

19. A new relationship with psychosis?
• CORE indicates clinical improvement –
but a new relationship with psychosis?
• Qualitative study (Abba et al., 2008:
Psychotherapy Research, 18, 77-87)
• Describe psychological process of freeing
themselves from tyrannical relationship
with psychosis

20. The tyranny of psychosis
• Powerlessness & fear
• Struggling for some quality of life & at
times very survival
• Little or no hope
• Sense of self defined by psychosis as:
bad, different, abnormal, worthless
• Main focus of attention & energy – even
when absent

21. Experiencing how to relate differently to psychosis
Centering in awareness of
voices, thoughts, images in
the moment
Allowing voices, thoughts,
images to come and go without
reacting/struggle
Reclaiming power through
acceptance
Opening
awareness to
include the
unpleasant
Beginning
again and
again
Anchoring
awareness
in breath
and body
Not trying
too hard
Concent-
rating
gently on
what is
present
Re-
connecting
with
present
experience
Letting go of
judgement,
fight, worry,
analysis
Seeing my
role in
alleviating
distress
Catching
myself in
habitual
reactions
Relaxing
into a
peaceful,
calm state
Recognizing
consequences
of reacting
Realizing
emotional
consequences
of letting go of
habitual
reactions
Accepting
voices,
thoughts,
images
Accepting
myself
Feeling
more in
control of
my mind
Deflating
psychosis
Knowing I
am more
than my
psychosis
Discovering
that I am not
different

22. Gracias
¿Alguna pregunta?