Borderline personality disorder (BPD) is one of the most challenging and confusing disorders within the realm of mental health. It’s been around since the 1930s. It was originally called “borderline” because it identified individuals who appeared to be experiencing a mild form of schizophrenia, and appeared to be on the borderline between neurosis and psychosis. So here we are, ninety-two years later, and what do we know, have things changed for practitioners and patients? I’d say a resounding YES! I’m going to identify three areas that show we’ve moved forward in our understanding, while also discussing points of confusion.

BPD Is Not a Pure Diagnosis but a Complex One

Many individuals still view BPD as the central cause of all the maladaptive beliefs, behaviors, and patterns seen in those with this full disorder or traits. The reality is that most individuals with BPD have comorbid conditions, and this combination creates a complex form of BPD that I call Complex BPD (CBPD). CBPD is estimated to account for 85 to 97 percent of all BPD cases. Knowing that such a high percentage of co-occurring issues exist will increase the awareness that cause and treatment needs to be taken into account when examining one’s life, behavior, perceptions, and consequences.

For example, major depressive disorder (MDD) has been found to occur in 83 percent of individual with BPD. Those individuals with CBPD that is made up of MDD and BPD need to be seen and treated in a very different way, as opposed to when these disorders occur alone. In the CBPD case, the MDD symptoms are likely driven by BPD content. This means that medication and cognitive-behavioral techniques that are directly targeted to depressive symptoms are going to have a diminished impact. However, interventions that focus on the underlying component, BPD, which drives the depressive symptoms, is likely to remit both BPD and MDD symptomatology. You have to know what you’re dealing with to deal with it effectively.

BPD and Other Personality Disorders Need to Be Understood Differently

Personality disorders are not made up of a single construct, but a dual construct. This means that there are two levels to consider when a personality disorder is present: core and surface content. Core content is made up of the internal parts of yourself that represent how you feel and think about yourself, others, and your world. Commonly identified core content in individuals with BPD includes abandonment and emptiness. Surface content often seen in those with BPD includes impulse control and substance abuse. These two constructs need to be explored and identified to achieve long-term change in individuals with BPD or others personality disorders.

For example, Betty has been diagnosed with BPD. She has a history of substance abuse and anger issues (surface content). In session, when Betty is asked about what drove her to use drugs and what activates her anger, she’ll tell you it’s because her partner did not respond to her texts, he is cheating on her (she has no evidence but she feels it so intensely), and it’s just a matter of time until he leaves her and she’s alone forever—leaving her as a “true spinster”. You’ll notice that the underlying issues are fear of abandonment and emptiness (core content). Betty engages in her surface content (drugs and anger) to manage her core content. When her core content is explored, she builds insight into it, and she is receptive and willing to learn and utilize more adaptive strategies such as mindfulness or freeze-consider-reengage, which gives her a greater sense of control. By only addressing her surface content, as many mental providers tend to do, she doesn’t develop the same level of insight and has greater difficulty managing her anger and drug use. The dual construct approach is critical, and knowing your core and surface content is a huge step in the direction of mastering self-control.

Not Knowing That BPD Is a Good Prognosis Diagnosis

BPD can be successfully treated and has a good prognosis. To attain therapeutic success, the mental health provider you’re working with needs to know this, but should also have experience in treating those with BPD, understanding the complexity of the diagnosis, and maintaining an open-minded perspective of the treatment course. Experience is a central component to achieve your therapeutic goals. Therapy is unlikely to be a linear process, such as only successes and no regressions. There will be periods of symptom remissions; times when symptoms lessen and the individual functions well. The antithesis is also likely to occur—resurgence of symptoms—and this is where the impact of experience is most powerful. The experienced clinician knows that these ebbs and flows occur and helps you manage them effectively, as opposed to feeling disheartened. The experienced clinician understands that the road is long and can be quite challenging, but the prognosis is a good one, and you need encouragement to hold on to hope for your success because it can be achieved.

Deepening your level of understanding and feeling empowered to confront your challenges along the way are invaluable resources you will need to keep going as you progress through treatment. You and your therapist need to know to look for themes and core content activations to build insight into your beliefs, behaviors, and patterns. You and your therapist need to align to peel back the armor of pathology and maladaptive surface content to block it and change it. This approach provides you and your therapist with the flexibility to change course when necessary; explore treatment goals that need to be fluid and not dogmatic; and to hold a steadfast, encouraging approach. Dealing with BPD has often left you feeling derided, rejected, and overwhelmed by a whole host of emotions and life experiences that have strengthened your pathology. Some of these may have been from past mental health providers. But the provider who knows the prognosis and embraces it, can help you rise to the challenge and empower you to learn and grow beyond your BPD.

What do you think makes BPD difficult to understand? What challenges and successes have you had that encouraged your growth, whether you’re a provider or patient. Remember, knowledge is power, and power is control, and control leads to choice—of not only where you go in life, but how you get there.

Daniel J. Fox, PhD, is a licensed psychologist in Texas, international speaker, and award-winning author. He has been specializing in the treatment and assessment of individuals with personality disorders for more than twenty years, and is author of several books, including The Borderline Personality Disorder Workbook.

The post What Makes Borderline Personality Disorder So Difficult? appeared first on New Harbinger Publications, Inc.

In honor of Mental Health Awareness Month, we reached out to anxiety expert and self-help veteran Edmund Bourne—author of the bestselling classic, The Anxiety and Phobia Workbook. Now in its sixth edition and recommended by therapists worldwide, this landmark workbook has been the unparalleled, essential resource for people struggling with anxiety and phobias for almost thirty years. Here, Bourne offers valuable insight to help readers understand what causes anxiety, combat stigma and misinformation in the media, and move past the fearful “self-talk” that fuels fear, worry, and panic.  

In the three decades since The Anxiety & Phobia Workbook was published, how have public perceptions of mental health challenges—and anxiety in particular—changed? Have they stayed the same?

Since 1990, the number of people willing to talk about someone they personally know with a mental health problem has doubled from about 30 to 60%. A larger proportion of the population recognizes that mental and behavioral problems are relatively common. So, in recent years, it has become more socially acceptable to talk about a friend or relative who has emotional difficulties. 

In addition, the number of people admitting their own mental health difficulties has increased. In recent years 20 to 25% of people are willing to discuss emotional difficulties with others outside the context of their closest friends or relatives, whereas less than 15 percent would share about their problems thirty years ago. And finally, much like the decline in stigma, fewer people regard seeking out help for a mental health problem to be a “sign of weakness.” 

Another major shift is that more people (up to 80%) deem mental health and physical health to be equally important. However, it is also apparent that a majority people perceive that more attention is given to physical illness than mental illness in our current health-care system. This is consistent with the fact that people who identify themselves as having emotional difficulties are less likely to seek out help than those with physical illnesses. Ethnic, racial, and socioeconomic factors predict how likely a person is to consult with a psychiatrist or psychologist versus trying to resolve their problems within their own family and broader community.

A final reason for lower utilization of mental health services is cost. Although the Affordable Care Act of 2010 increased the availability of mental health coverage, about 15% of adult Americans reported in 2015 that either they or household members had difficulty getting mental health care coverage.

What are some of the myths about anxiety and phobias that you would like to dispel?

A list of some of the most common myths about anxiety and phobias was compiled by the ADAA (Anxiety & Depression Association of America) in 2017. They include:

Having a phobia such as fear of seeing doctors or a fear of going far from home is an indication of being “crazy.”

The term “crazy” is a word often used carelessly to refer to any behavior or emotional challenge that doesn’t fall into the range of culturally normative behavior. One of the first things anxiety specialists need to do with clients is dispel any notions that they could go “crazy” or “insane.” Anxiety disorders in general simply don’t lead to the kinds of problems associated with psychotic conditions such a schizophrenia or bipolar disorder. In fact, there is an inverse relationship between having an anxiety disorder and having a psychotic disorder. Use of the term “crazy” to refer to an anxiety disorder is a false attribution.

A phobia is just an overrated fear.

When thought of as an overrated fear, someone might tell the phobic individual to “just get over it.” In truth, having a phobia can be a disabling problem that interferes with personal relationships and/or the ability to perform one’s job or go to school. The good news is that most phobias are readily treatable by a combination of exposure therapy and cognitive behavior therapy (CBT). However, a phobia is much more than an overrated fear.

If a panic attack gets too bad, you can pass out.

Panic attacks may cause very unpleasant sensations and feelings, but you won’t faint from one. During a panic attack, your heart is usually beating faster and harder, promoting increased blood flow to the brain, which is the opposite of what happens when fainting occurs (due to a slight decrease in cerebral blood flow).

If you feel anxious, it’s important to avoid stress or anxiety-producing situations.

A paradox about anxiety and phobias is that the more you try to avoid them, the worse they tend to get. Effective treatment of both panic attacks and phobias involves gradual exposure (i.e., incrementally facing) the very internal body sensations or external real-life situations your anxiety tries to persuade you to avoid.

The causes and roots of anxiety disorders are typically rooted in childhood.

Decades of research indicate that the most effective treatments for anxiety disorders deal with the here and now. The preferred treatment for anxiety disorders, CBT, teaches you strategies to manage fearful thoughts and emotions, as well as how to stop escaping internal sensations or outside situations you may have been avoiding in an effort to minimize fear.

Medications are the best treatment for anxiety disorders.

Research over decades has shown that while medication can be helpful, CBT is just as effective, and in some cases more effective than medication in treating anxiety. Many mental health practitioners use a combination of medication (such as an SSRI antidepressant) and CBT to most effectively treat anxiety disorders.

In our modern, fast-paced, and often troubling world, how do you know if you suffer from an anxiety disorder or if you’re simply worried about life/world events?

Anxiety is an inevitable part of life in contemporary society. It’s important to realize that there are many situations that come up in everyday life in which it is appropriate and reasonable to react with some anxiety or worry. If you didn’t feel any anxiety in response to everyday challenges involving potential loss or failure, something would be wrong. 

Anxiety disorders are distinguished from everyday, normal anxiety in that they involve anxiety that is 1. more intense (for example, panic attacks), 2. lasts longer (anxiety that may persist for weeks or even months after a stressful situation has passed), or 3. leads to phobias that interfere with your life.

Criteria for diagnosing specific anxiety disorders have been established by the American Psychiatric Association and are described in a well-known diagnostic manual called the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders—Fifth Edition).

If you’re concerned about whether you have a diagnosable anxiety disorder, you may consult chapter one of The Anxiety & Phobia Workbook, which provides detailed descriptions—as well as treatment recommendations—for each of the five major anxiety disorders: panic disorder, agoraphobia, social anxiety disorder, specific phobia, and generalized anxiety disorder, as well as two additional disorders that are generally though of as anxiety disorders through currently classified separately: obsessive-compulsive disorder and post-traumatic stress disorder.  

What causes anxiety? Is it biological? Situational? Environmental?

Anxiety difficulties are brought about by a variety of causes operating on different levels: heredity, neurophysiology, family background and upbringing, conditioning, recent stressors, your self-talk (internal thought-processes) and belief systems, your ability to express your feelings and assert yourself, and numerous other factors. 

There is no single cause of an anxiety disorder. Heredity and childhood circumstances play a predisposing role, but there also are many short-term, triggering causes that precipitate an anxiety disorder, such as a significant personal loss or trauma, a significant life change, or even use of stimulants and recreational drugs. Once you have acquired an anxiety disorder, there are many “maintaining causes” that can contribute to keeping it going, such as avoidance of anxiety provoking situations, anxious self-talk (fearful thoughts), mistaken beliefs, a high-stress lifestyle, personality traits such as perfectionism, poor nutrition, withheld feelings, or even a lack of meaning and sense of purpose in your life. 

For a detailed discussion of the many causes of anxiety disorders, see chapter 2 of The Anxiety & Phobia Workbook. The remaining seventeen chapters of the book describe a wide range of strategies for overcoming each of the maintaining causes of anxiety disorders described above as well as several others.

How can we move past the stigma associated with anxiety and other mental health disorders so that more people seek the treatment they need?

Many people who live with mental illness are at some point blamed for their condition. They may be called names, told they are “going through a phase,” or, if they just “tried harder,” they could gain control over their problems.

Unfortunately, being blamed for something that is mostly out of one’s control promotes shame and guilt. In turn, shame can lead to discouragement about seeking treatment. If you feel ashamed of your condition, you may be less motivated to seek help for it.

The National Alliance on Mental Illness (NAMI), a grassroots organization the promotes education about mental health issues, offers a list of guidelines about reducing mental health stigma:

Some of the key guidelines include:

Education that mental health issues such as anxiety disorders or depression are genuine health problems that respond to professional help. For example, sharing books with significant others or friends that describe the nature, causes, and treatments for anxiety disorders, such as The Anxiety & Phobia Workbook, can assist with raising awareness that the problems are real.

1. Being conscious of language. Even a modicum of education leads to elimination of the use of adjectives that are entirely inappropriate, such as “weak,” “crazy,” “weird,” or even terms that borrow from names of conditions such as “obsessed” or “depressed.”

2. Encouraging equality between mental and physical illness. When people understand that mental health issues are significant problems—just as serious as physical illnesses—they can better appreciate what people with anxiety or mood disorders are going through as well as the need to seek out professional help. This also de-stigmatizes the use of prescription medications to treat mental health problems.

3. Self-empowerment. In brief, self-empowerment means owning your own life and refusing to allow others, who may not understand mental health issues, to dictate how you view or feel about yourself. 

4. Compassion. Understanding the nature and challenge of mental health difficulties should promote more care, concern, and an increased sense of humanity toward those who struggle to overcome these types of problems.

5. Correcting broadcast and social media stigma. Though stigmatizing mental illness on TV has declined considerably in recent years, it’s important to call it out by contacting the broadcasting company or the program when it occurs. Stigmatizing posts or tweets on social media can be directly countered by posting/writing corrective educational material about mental health problems.

Why is cognitive behavioral therapy (CBT) so effective in treating anxiety disorders?

In head-to-head research comparisons between medication and therapy to treat anxiety disorders such as panic attacks, social anxiety, phobias, generalized anxiety, and obsessive-compulsive disorder, CBT has consistently proven to be equal or superior to medication. In some cases, the combination of CBT and medication has been shown to be very effective as well.   

While there are many approaches for tackling anxiety disorders, CBT relies on a time-honored principle: what we say to ourselves mentally in response to any situation largely determines our mood and feelings about the situation.

The realization that what you think to yourself—your “self-talk”—is largely responsible for how you feel is empowering once you fully accept it. It is an important key to living a happier and more effective life.

People who suffer from anxiety are especially prone to suffer from fearful self-talk. Anxiety can be generated on the spur of the moment by internal mental thoughts (self-talk) that begin with the two words “what if.” The anxiety you experience in anticipation of a challenging situation arises largely from your own “what if” statements within your mind. When you decide to avoid a situation altogether out of fear, it’s likely because of scary questions you’ve asked yourself: “What if I panic?” “What if I can’t handle it?” “What will other people think of me if they see me anxious?” “What if I lose control or even go crazy?” These are a few among many so-called “catastrophic thoughts” that tend to generate panic, avoidance, or general anxiety. 

CBT is a step-by-step process of learning to 1. identify, 2. challenge, and 3. replace catastrophic thoughts with more realistic and constructive thoughts. As mentioned, research over the past three decades has shown consistently that CBT can be effective in reducing fearful thinking that drives anxiety disorders. CBT can be practiced on your own or with the assistance of a trained therapist. The following example illustrates how the various steps of CBT work:

1. Identify the fearful, catastrophic thought: “I have low energy and feel tired a lot of the time—what if I have cancer and don’t know it?’

2. Question the validity of the fearful thoughts: What are the realistic odds that feeling low energy and fatigue actually mean I have cancer? There are obviously many reasons why I could have low energy, such as allergies, stress, or even a non-threatening medical condition such as anemia. In the unlikely instance that I had actually had cancer, how terrible could that be? Would I actually go to pieces and not be able to continue living?

3. Replace fearful thoughts with more constructive thoughts. Symptoms of fatigue and low energy can be indicative of all kinds of physical and psychological conditions, including a low-grade virus, anemia, hypothyroidism, depression, or food allergies, just to name a few. There are many possible explanations of my condition, and I don’t have specific symptoms that would suggest cancer. So, the odds of my low energy and fatigue being indicative of cancer are very, very low.

Edmund Bourne, PhD, has specialized in the treatment of anxiety, phobias, and other stress-related disorders for over two decades. His self-help books have helped over a million people and have been translated into numerous languages. He currently resides in Florida and California.

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Almost all models of psychotherapy agree on the power of metaphors in the therapeutic dialogue. And different models provide different metaphors to use for different kinds of problems. But a lot of metaphors appear spontaneously, without the person using them even being aware that what they’re saying is metaphorical. A therapist can focus on these spontaneously used metaphors—many conventional or “frozen”—in building alliance and targeting other specific, important areas.

One such area would be helping the client make the connection between what they do in certain problematic situations and the consequences experienced—what is typically called a functional analysis or an A–B–C analysis (Antecedent–Behavior–Consequence).

So, if a client describes their situation by using a conventional metaphor, like in saying: “I am up against a wall; I don’t know what to do,” the therapist can catch the metaphor about being up against a wall and try to develop it in cooperation with the client. Ways to respond would be: “Tell me more about the wall!” or “How do you recognize the wall?” or “In what situations would the wall typically appear?” If the client responds to these interventions “within the metaphor,” an alliance is built and the description of the problematic antecedents are deepened. To focus on what the client does in this situation, the next step could be asking: “When you sense the wall, when you are up against it, what do you typically do?” And if the dialogue continues within this metaphoric frame, a question could be asked about the connection between what is done and the result—the connection between behavior and consequence: “So, the wall appears, you try to X, and then what happens?”

Two things are fundamental in this kind of dialogue: first, the therapist needs to recognize metaphoric expression, and second, have a strategy for what to use them for, as in the above example about functional analysis.

Niklas Törneke, MD, is a psychiatrist, and has worked as a senior psychiatrist in the department of general psychiatry in his hometown of Kalmar, Sweden, from 1991 until he started a private practice in 1998. He earned his license as a psychotherapist in 1996, and was originally trained as a cognitive therapist. Since 1998, he has worked mainly with acceptance and commitment therapy (ACT), both in his own practice and as a teacher and clinical supervisor. His clinical experience ranges from psychiatric disorders such as schizophrenia to common anxiety and mood disorders with high prevalence in the general population.

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What does non-duality mean to you?

Historically, non-duality refers to “not two,” or seeing through the illusory separation (duality) in life. Although I like that definition, there is a more accessible way of talking about non-duality. When we are thinking, our thoughts are dividing up reality into “this” and “that.” Thoughts make it appear that reality is a fragmented collection of separate things. As we begin to investigate thought (through witnessing or inquiry) and recognize the awareness to which all those thoughts are appearing, we begin to see that they are just thoughts. They don’t really point to separate things. They just arise and fall to awareness. Eventually, in a non-dual recognition, the mind begins to quiet and we experience non-conceptual presence as the foundation of our experience. In that presence, when no thoughts are arising, increasingly reality is seen as undivided. Embodiment is an important component of non-dual recognition, in my view. It happens as we begin to include (in our witnessing or inquiry) the emotions and sensations that are stuck to thoughts. When an emotion or sensation is stuck to a thought, the thought seems more true or real. It seems to really point to a separate self and separate things. As these emotions or sensations are allowed to be, they are seen to come and go. They unglue themselves from thoughts, making thoughts seem less true or real.

How did you find non-duality, and when did you begin integrating it into your work?

Once I stopped abusing painkillers (which lasted for over fifteen years), I went on a mad search to find whatever was out there in the world that would help me deal with the thoughts and emotions I had been running from and trying to manage with the painkillers. I looked at every religion and as many therapies and positive-thinking strategies as I could find. Instantly, I saw the wisdom of non-duality when I first began to read about it. There was no “work” of mine at first. The work came from the realizations and insights I was having in my own life. I just wanted to share them. That sharing became my “work” over time.

Your message on Kiloby.com is “Rest. Inquire. Enjoy Life.”—can you explain what that means?

Yes, it sums up my teaching completely, and it’s about going as deep as you can go as well as maintaining balance in your life. “Rest” refers to resting as awareness and allowing all thoughts, emotions, and sensations to be noticed and allowed, which also reveals that they are temporary arisings to awareness. Although this practice is foundational to my work and many other non-dual teachings, it often doesn’t go far enough to truly help people see through the illusion of separation. That’s where “Inquire” comes in. Here, I’m specifically referring to the Living Inquiries, which were developed by me and my team of facilitators. They can be found at LivingInquiries.com. My new book, The Unfindable Inquiry: One Simple Tool to Overcome Feelings of Unworthiness and Find Inner Peace, is an instruction book on the Unfindable Inquiry, which is the basis for all the Living Inquiries. Inquiry is so important to help us see through the stickiest and most dense aspects of our belief in being a separate self, and in separation generally. They help undo what I call the “Velcro Effect,” which—as I explained above—is the experience of emotions and sensations being stuck to thoughts. “Enjoy Life” is about the balance. These kinds of teachings are not about obsessing on rest, awareness, inquiry, or spirituality. What’s the purpose of a teaching or method if it does not free you up to experience a greater enjoyment, ease, creativity, and enthusiasm for life? As we rest and inquire, our capacity to take ourselves less seriously allows us to enjoy life more, in whatever way that shows up for each of us.

What are the Living Inquiries, and how were they developed?

I developed the Unfindable Inquiry (UI) in 2008 during a period in which I was experiencing a core deficiency story that had remained after my awakening experience in 2007. The core deficiency story was “I am unlovable.” Recognizing awareness was not enough. I needed a more potent tool. Through my extensive conversations with Greg Goode—who I consider both a friend and one of my greatest teachers—I developed the Unfindable Inquiry as a way to see through this very deeply rooted aspect of my ego, which was created in part through trauma as a result of being bullied for being gay when I was in elementary school. The UI was the only thing that really helped. I stopped reading non-duality books at that point. I needed something more penetrative and direct.

After developing the UI, I began to train others to be facilitators of it. Eventually, I and that team of facilitators—including Fiona Robertson, Colette Kelso, and Julianne Eanniello—developed the Compulsion Inquiry (for addiction) and the Anxiety Inquiry (for trauma and anxiety). Each of these together assist in investigating the three forms of suffering discussed in Buddhism (fear, desire, and ignorance of the nature of reality).

There is now a worldwide Living Inquiries facilitator training program including around 100 facilitators who use this work in 12 different countries. The work is also used at the Kiloby Center for Recovery and is being brought into various other treatment centers across the United States.

Are the Living Inquiries for everyone?

They are not for people who believe that non-dual teachings are about learning a lot of knowledge about the teachings and being an expert on them. They are for people who know that knowledge does not bring freedom. The Inquiries are experiential. They are perfect for people who are no longer interested in just reading about non-duality and who want to actually investigate the nature of reality and their own limiting beliefs. The Inquiries, alone, are not sufficient to deal with some mental illnesses, like schizophrenia. Medication is often needed in that case. But inquiry can help once someone is stabilized.

You cofounded the Kiloby Center for Recover (KilobyCenter.com)—how did that come about?

I was traveling the world giving talks, workshops, and seminars, and I was approached by a gracious investor who wanted to bring my work, Natural Rest for Addiction, into a treatment center. I already had the idea years ago, but this investment made it happen. The Kiloby Center is truly a labor of love. It’s exactly where I eventually wanted to take my work—into the trenches where people are suffering with addiction, trauma, anxiety, and depression. That dream came true.

What is Natural Rest?

Natural Rest is just a phrase referring to restful non-dual awareness and seeing that everything comes and goes (all thoughts, emotions, and sensations), and that none of them are me. The rest is natural because it’s already in the here and now. We don’t have to take medication or do anything other than notice it.

The Kiloby Center offers an alternative to the 12-step approach to recovery—what makes your program different, and how might it complement the 12-step approach?

Many of our clients do participate in 12-step programs in addition to our work. Both the 12 steps and my work are about spiritual awakening. However, non-duality, in my view, is a much more effective way of experiencing a true spiritual awakening. After being in the 12 steps for several years in my own recovery, I had to leave, noticing that the spiritual awakening really wasn’t happening.

The Kiloby Center is the first mindfulness-based treatment center in the United States. That’s what makes it unique.

Some people see non-duality as an invitation to avoid taking action, such as seeking help—what would you say to people who suggest that because there is no separate person or doer, there is no need for a program like yours?

It’s not that simple. With the exception of a very rare few, most people don’t actually just see there is no separate self and then never need to investigate or seek help again. Life is fluid, and the body and mind store all kinds of unconscious material that keep the ego in place and keep addiction, trauma, and anxiety in place on some level, even after a spiritual awakening. My work is about investigating as deeply as one can into this unconscious material. Usually, after people do this work for a while, they never say again, “There is no self and therefore nothing to investigate.” They have investigated. They see that there is no end to the depth of freedom. Also, those who say, “There is no self,” are often only getting that on an intellectual level. They haven’t truly experienced that in the deepest and most profound ways. The few people whom I have met that have truly gone that deep do not say those things. “There is no self” can also be a way to bypass real issues that people avoid looking at. In the end, there is no self. That’s true. But it isn’t the final realization. Even that falls away… We then find ourselves back in life (having never left), but more engaged and freer to be, move, and act in the world in compassionate, selfless, and loving ways. At that point, we have seen that even self versus no-self is a duality. That is also seen through with the Inquiries.

What support can the Living Inquiries and Natural Rest offer for the family, friends, and significant others of people recovering from addiction?

The Kiloby Center has a family program run by senior facilitators Kay Vogt (who is also a psychologist) and Lynn Fraser. Family members of clients at the Kiloby Center participate in that program. But it is open to any families struggling with family members who are addicted. I cannot emphasize enough how important and vital it is for family members to heal—not just the addicted person.

Your first book with Non-Duality Press was Reflections of the One Life—what inspired that book?

There was very little thought put into it. As with all of my books, the inspiration just arose. Every morning I felt drawn to writing a daily reflection. I did that for a year, and that book is the result. I was in the midst of many insights coming up. I wanted to write them down. That’s all.

In Living Realization, your second book with Non-Duality Press, you describe Living Realization as “nothing short of a love affair with life”—can you tell me more about that?

People don’t love themselves generally. They carry core deficiency stories such as “I’m not good enough,” “I’m unsafe,” or “I’m unimportant.” When you don’t love yourself, you cannot truly love others or love life. Using the Unfindable Inquiry, which was first introduced in my book Living Realization, you can investigate these core deficiency stories—which lie at the heart of the feeling of separation—and come to see through them. But Living Realization is mostly focused on presenting a very accessible way of recognizing non-dual awareness as the foundation of experience, then allowing all thoughts, emotions, and sensations to be as they are, and no longer identifying with them. As you begin to accept, allow, and love whatever is arising (even pain), you essentially fall deeper into that realization, like falling in love. But this is not the romantic love that we all know. It’s an unconditional openness toward experience itself. For example, as a painful emotion arises, you allow it to be just as it is (by undoing the Velcroed thoughts associated with it). You allow it, without trying to change or get rid of it. That is the openness. Because life is really the experience of whatever is arising, that’s how you fall in love with life. You fall in love with experience itself as it arises in the moment.

What was the motivation for your new book, The Unfindable Inquiry?

I just wanted to let others know how the Unfindable Inquiry works. The best way to do that was to put it in book form, complete with examples from sessions with people where I used the UI to guide them to see through the darkest and most painful aspects of their experience.

The Unfindable Inquiry presents both the Boomerang Inquiry and the Panorama Inquiry as relationship inquiries—how can these help people struggling in relationship?

The Unfindable Inquiry is the basic inquiry we use in the Living Inquiries. The Boomerang Inquiry is a way of seeing how another person reflects back a certain ego-based story, usually a story of deficiency. The Panorama Inquiry is a way of seeing how multiple people mirror back the same story to you. Once you really begin to see how all relationship is mirroring back your identity, you can use the UI to see through that identity. This results in less triggers, more harmony, and peace in relationship. It’s like cleaning a lens through which you’ve been seeing yourself, others, and the world. As the lens is cleaned, relationships are no longer as painful as they were before and can even be quite easeful, loving, and compassionate.

What’s next for you?

I have recently been hired as the COO of MyLife Recovery Centers. MyLife has the patent for the Naltrexone Implant, an amazing new medicine that greatly reduces or eliminates cravings for alcohol and opiates for many months. The implant really helps people focus on our work at the Center, rather than on the drug. MyLife has asked the Kiloby Center to develop its behavioral health program across the United States. It’s very exciting.

Check out The Unfindable Inquiry—available now!—and look for Natural Rest for Addiction, coming this May from Non-Duality Press.

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Given the often extremely isolating nature of the experience of psychosis, an approach that has at its core the appreciation of the ubiquity of suffering and our common humanity encourages connection between the client and therapist. A normalizing approach, including the metaphor of therapist and client as co-travelers, is implicitly humanistic, destigmatizing, and depathologizing. This understanding of the therapeutic relationship enables the client (and clinician) to experience a greater sense of connectedness. In their model, the therapeutic relationship is oriented toward wellness versus illness and strengths versus symptoms or pathology, and it emphasizes recovery, values, and pursuit of valued life goals.

One such example of this type of approach, based on CBT for psychosis, was developed by Nicola Wright, Douglas Turkington, and the other authors of Treating Psychosis: A Clinician’s Guide to Integrating Acceptance and Commitment Therapy, Compassion-Focused Therapy, and Mindfulness Approaches within the Cognitive Behavioral Therapy Tradition. Their approach emphasizes a deep and sophisticated understanding of the experience of psychosis rather than a superficial attempt at “challenging and eradicating” the client’s symptoms. It focuses on the process and function of thoughts and behaviors. For example, they emphasize investigation into what purposes worry, rumination, and attention to threat serve for the client, and what are the client’s beliefs regarding the pros and cons of each?

The therapeutic alliance—which was recently shown to be a powerful determinant in treatment outcomes with psychosis clients—and goals are based on the client’s values and valued goals in therapy that are synergistic with the overarching model (and the clinician’s values). This yields an increased focus on the integration of values and one’s experience of self and relationships in the therapeutic work. The therapeutic approaches are used by both the client and the clinician—for example, the clinician engages in mindfulness practice and incorporates a mindful approach to self and the client in the therapeutic relationship (Siegel, 2010). Thus, a beautiful synergy emerges as the therapeutic relationship is implicitly, in and of itself, an empowering and emotion-regulating relationship within which the client is able to strive for optimal well-being.

A number of issues can come up in therapeutic work with those who experience psychosis, issues that call for a therapeutic relationship that is built on compassion, trust and validation. For example, clients can be hesitant to discuss thoughts, beliefs, and voices due to therapeutic safety concerns; perceived judgment by others and self-stigma related to the diagnosis of “schizophrenia” or the fact that one hears voices can present a barrier that may limit client disclosure. Understanding that clients may perceive potential for increases in medication or length of stay if they report unusual thoughts or experiences to health care providers can also impact their willingness to work on certain issues or topics in therapy. To ensure that the client feels comfortable disclosing the truth about their experiences, what you’ll disclose should be discussed with the client at the beginning of treatment. This and all other client concerns should be addressed proactively and transparently.

To further enhance safety and trust, therapy should be adjusted to address any increase in symptoms. Individualizing treatment is critical. Instead of working directly with symptoms like voices by exploring their identity or content, the client’s relationship to them, and so on, therapeutic work should aim to identify the client’s individual values and goals, and the core beliefs (such as those underlying low self-worth) that drive the theme and content of the symptoms. By focusing on core beliefs and schemas, it’s then possible to undermine the core beliefs supporting the content and believability of distressing symptoms. The “symptoms” can also serve other purposes, such as a compensatory purpose (for example, making the person feel special or important) or that of staving off loneliness. Therefore, it is essential to take a compassionate and curious approach to understanding what purpose symptoms may serve for the client.

Another area where a compassionate therapeutic approach specifically may be called for is when isolation or loneliness is an issue. Activity scheduling, including social activities, can be done with the client. If a sense of worthiness and value is an issue, coping strategies, self-esteem-enhancing strategies, and value-driven goals can be an initial and ongoing focus. A focus on valued goals can redirect energies from the client’s preoccupation with symptoms to more strengths-focused and meaningful pursuits. Exploring the advantages and disadvantages of the amount of time and energy spent on symptoms using motivational interviewing strategies can help the client to engage in more meaningful, goal-directed activity or committed action.

A compassionate therapeutic approach to the lived experience of clients is fundamental. The therapeutic stance should be one of respect, compassion, understanding, and normalization. Through this therapeutic stance, the client experiences validation and safety in the therapeutic relationship and is able to work toward meaningful life goals.

For more about the approach developed by Nicola Wright, Douglas Turkington and their colleagues, check out their book, Treating Psychosis: A Clinician’s Guide to Integrating Acceptance and Commitment Therapy, Compassion-Focused Therapy, and Mindfulness Approaches within the Cognitive Behavioral Therapy Tradition.

References

Siegel, R. D. (2010). The mindfulness solution: Everyday practices for everyday problems. New York, NY: Guilford Press.

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According to Kabat-Zinn (2003), mindfulness can be defined as “the awareness that emerges through paying attention on purpose, in the present moment and nonjudgmentally, to the unfolding of experience moment to moment.” Though mindfulness is a central and integral part of both acceptance and commitment therapy and compassion-focused therapy, we haven’t yet had a chance to look at how it has also been incorporated in CBT as a strategy and treatment approach (mindfulness-based cognitive therapy; Segal, Teasdale, & Williams, 2002, 2012).

Mindfulness-based approaches have been applied to psychosis, with some modifications. Chadwick (2006) and Chadwick and colleagues (2005, 2009) have emphasized the implementation of mindfulness with those who experience psychosis. There is preliminary evidence that completion of mindfulness-based therapy is feasible for clients with psychosis, and can positively impact overall psychological well-being and improve the ability to respond mindfully to stressful internal events (for example, Abba, Chadwick, & Stevenson, 2008; Chadwick, Newman-Taylor, & Abba, 2005; Chadwick, Hughes, Russell, Russell, & Dagnan, 2009; Langer, Cangas, & Serper, 2011; Langer, Cangas, Salcedo, & Fuentes, 2012).

As Kabat-Zinn’s definition of the term makes clear, the mindfulness process involves a nonjudgmental accepting of one’s internal and external experiences. The process of coming into contact with distressing thoughts (or delusions) and feelings and experiences such as hallucinations and letting them pass without reacting to them enables exposure rather than the avoidance so often associated with “negative” or disturbing delusions and hallucinations.

The decentered awareness in mindfulness facilitates the experience of cognitions as mental events in a broader context, and thereby facilitates a more metacognitive stance of decentering or defusing rather than getting “caught” in or reacting to thoughts or delusions, images, and hallucinated voices. The awareness and acceptance of thoughts, images, sounds, and/or hallucinated voices (positive or negative) diminishes the processes of judgment and self-criticism, including the internalized self-stigma that is so often present in those who experience psychosis.

Finally, present awareness provides an alternative process to the maladaptive processes of rumination and worry that so frequently accompany psychosis. As described in ACT, mindfulness-based approaches allow for a reduction in distress and an enhanced ability to engage in meaningful activities and the pursuit of valued goals (Harris, 2009).

A principal focus of mindfulness is to regard thoughts as “mental events” rather than accurate reflections of reality (Teasdale et al., 2000). Assuming this objective, detached stance toward thoughts is hypothesized to prevent the escalation of negative thought patterns that precede and follow deleterious psychological states such as psychosis (Teasdale, Segal, & Williams, 1995). It also allows clients to potentially foster a different relationship with these thoughts. This can be paramount in the context of psychosis, as symptoms and distressing beliefs may not abate with even aggressive pharmacological treatment.

Another modality incorporated in the integrative protocol, behavioral activation (BA), is an empirically supported psychotherapy for the treatment of depression (Lejuez, Hopko, & Hopko, 2001). Although principles of BA techniques were largely subsumed within general CBT procedures (for example, Beck et al. 1979), there has been increasing interest around stand-alone BA protocols, given that it has been demonstrated that BA is as effective as full cognitive therapy in treating depression both in the short (Jacobson, Dobson, Truax, & Addis, 1996) and long term (Gortner, Gollan, Dobson, & Jacobson, 1998).

BA seeks to increase exposure to the positive reinforcement that comes with engaging in healthy behaviors by providing a structured framework and rationale to reactivate behaviors, such as social interaction, that become largely dormant in depression. Ideally, as individuals become more activated in social and other domains, the reinforcement they receive increases, thus increasing the likelihood of further engagement in healthy behaviors at the expense of depressed behaviors. It is believed that this change in behavior will ultimately shift mood in a positive direction (Lejuez et al., 2001).

Elements common to most BA protocols include psychoeducation around the influence of behavior on thoughts and emotions, identification of values and goals, mood and activity monitoring, activity scheduling, and graduated exposure to previously avoided activities.

It has been suggested that the negative symptoms of psychosis such as amotivation, alogia, and blunted affect reflect an attempt by the individual to moderate exposure to the consequence of positive symptoms, including the symptoms themselves, psychiatric treatment, and negative evaluations by others (Mairs, Lovell, Campbell, & Keeley, 2011). In addition, research indicates that negative symptoms are associated with defeatist beliefs about mastery and pleasure (Khoury & Lecomte, 2012). As in depression, this restriction of activity is strongly reinforced while simultaneously depriving the individual of the ability to access positive reinforcement for more value-driven behaviors (Mairs et al., 2011).

SEE ALSO: Acceptance and Commitment Therapy for Psychosis

Despite the suggested theoretical overlap between depression and negative symptoms of psychosis (for example, Hogg, 1996), there has been little investigation with respect to the efficacy of BA techniques in improving negative symptoms. In a pilot study by Mairs and colleagues (2011) employing a sample of eight individuals with negative symptoms of psychosis, it was found that treatment with a BA protocol was largely feasible and associated with reduced symptoms of depression and enhanced functional status. Importantly, treatment reduced negative symptoms while not evoking positive symptoms; however, these initial gains were maintained in only half of the participants at follow-up. While no firm conclusions can be drawn from this pilot study, the results align with the theoretical benefit that BA techniques may provide around activation and engagement in therapy and valued life goal attainment, thereby ameliorating negative symptoms of psychosis.

The integrative treatment model for psychosis that forms the foundation for the model presented in Treating Psychosis (LINK) reflects a synthesis of elements of each of the interventions we’ve discussed throughout the previous posts in this series. The core principle is the importance of the client’s identified values in driving shifts in thoughts, behaviors, and emotions with the ultimate goal of living a more meaningful and fulfilling life. Flowing from this, clients will benefit from developing mindful awareness of the present moment in order to allow the possibility of observing the function of emergent thoughts and/or behaviors relative to stated goals and, ultimately, values. 

This stance can foster cognitive flexibility, which helps clients to disengage from the struggle they are engaged in with distressing psychotic experiences, which is often reflected in substance use and other forms of cognitive and/or experiential avoidance.

For more on this groundbreaking integrative protocol, check out Treating Psychosis: A Clinician’s Guide to Integrating Acceptance and Commitment Therapy, Compassion-Focused Therapy, and Mindfulness Approaches Within the Cognitive Behavioral Therapy Tradition.

References

Abba, N., Chadwick, P. D. J., & Stevenson, C. (2008). Responding mindfully to distressing psychosis: A grounded theory analysis. Psychotherapy Research, 18, 77–87. doi:10.1080/10503300701367992

Chadwick, P., Newman-Taylor, K., & Abba, N. (2005). Mindfulness groups for people with psychosis. Behavioural and Cognitive Psychotherapy, 33, 351–359. doi:10.1017/S1352465805002158;

Chadwick, P. K. (2006). How social difficulties produce cognitive problems during the mediation of psychosis: A qualitative study. International Journal of Social Psychiatry, 52, 459–468.

Chadwick, P., Hughes, S., Russell, D., Russell, I., & Dagnan, D. (2009). Mindfulness groups for distressing voices and paranoia: A replication and randomized feasibility trial. Behavioural and Cognitive Psychotherapy, 37, 403–412. doi:10.1017/S1352465809990166

Gortner, E. T., Gollan, J. K., Dobson, K. S., & Jacobson, N. S. (1998). Cognitive-behavioral treatment for depression: Relapse prevention. Journal of Consulting and Clinical Psychology, 66, 377–384. doi:10.1037/0022-006X.66.2.377

Harris, R. (2009). ACT made simple. Oakland, CA: New Harbinger Publications.

Hogg, L. (1996) Psychological treatments for negative symptoms. In G. Haddock & P. D. Slade (Eds.), Cognitivebehavioural interventions in psychotic disorders (pp. 151–167). London, UK: Routledge.

Jacobson, N. S., Dobson, K. S., Truax, P. A., Addis, M. E., Koerner, K., Gollan, J. K., et al. (1996). A component analysis of cognitive-behavioral treatment for depression. Journal of Consulting and Clinical Psychology, 64, 295–304. doi:10.1037/0022-006X.70.2.288

Kabat-Zinn, J. (2003). Mindfulness-based interventions in context: Past, present, and future. Clinical Psychology: Science and Practice, 10, 144–156.

Khoury, B., & Lecomte, T. (2012). Emotion regulation and schizophrenia. International Journal of Cognitive Therapy, 5, 67–76. doi:10.1521/ijct.2012.5.1.67

Langer, A. I., Cangas, A. J., & Serper, M. (2011). Analysis of the multidimensionality of hallucination-like experiences in clinical and nonclinical Spanish samples and their relation to clinical symptoms: Implications for the model of continuity. International Journal of Psychology, 46, 46–54.

Langer, A. I., Cangas, A. J., Salcedo, E., & Fuentes, B. (2012). Applying mindfulness therapy in a group of psychotic individuals: A controlled study. Behavioural and Cognitive Psychotherapy, 40, 105–109. doi:10.1017/S1352465811000464

Lejuez, C. W., Hopko, D. R., & Hopko, S. D. (2001). A brief behavioral activation treatment for depression: Treatment manual. Behavior Modification, 25, 255–286.

Mairs, H., Lovell, K., Campbell, M., & Keeley, P. (2011). Development and pilot investigation of behavioral activation for negative symptoms. Behavior Modification, 35, 486–506. doi:10.1177/0145445511411706

Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2002). Mindfulness-based cognitive therapy for depression: A new approach to preventing relapse. New York, NY: Guilford Press.

Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2012). Mindfulness-based cognitive therapy for depression (2nd ed.). New York, NY: Guilford Press.

Teasdale, J. D., Segal, Z. V., Williams, J. M. G., Ridgeway, V. A., Soulsby, J. M., & Lau, M. A. (2000). Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy. Journal of Consulting and Clinical Psychology, 68, 615–623. doi:10.1037//0022-006X.68.4.615

Teasdale, J. D., Segal, Z. V., & Williams, J. M. G. (1995). How does cognitive therapy prevent depressive relapse and why should attentional control (mindfulness) training help? Behaviour Research and Therapy, 33, 25–39. doi:10.1016/0005-7

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The foundation and philosophy underlying their integrated treatment approach is based on positive psychology and recovery principles—that is, it is “positive psychology–infused.

Positive psychotherapy is an empirically validated, strengths-focused approach to therapy that emphasizes client strengths and positive emotions to enhance life meaning, well-being, and happiness (Seligman, 2002). Positive therapy approaches are implicit in the recovery movement for those with lived experience of psychosis (Copeland, 2010). The approach is inherently empowering, destigmatizing, and affirming. Rather than focusing predominantly on symptoms, deficits, distressing emotions, and pathology, a positive psychology orientation incorporates strengths, qualities, resources, and an emphasis on the development of positive, pleasurable emotions to move in the direction of valued life goals and enhance meaning in life. In positive psychotherapy, strengths and positive emotions are crucial to engagement, a healthy therapeutic alliance, and a foundation and focus for treatment.

Another element of the protocol is the piece drawn from compassion-focused therapy (CFT), which directly addresses high levels of shame and self-criticism that are often present in clients suffering from psychosis. Those who struggle with elevated levels of shame and self-criticism born from a history of abuse, neglect, or bullying often do poorly in therapy and are unable to feel safe and equal in their relationships with others (Gilbert, 1992; Gilbert, 2009). Importantly, shame and self-criticism evoke maladaptive patterns of thought and behavior that serve to maintain and exacerbate negative internal states such as psychosis (Gilbert et al., 2001).

In the context of CFT, compassion reflects specific skills and attributes, the foremost being compassionate mind training (Gilbert, 2009), a collection of techniques that facilitate the individual’s increased awareness of negative interactions with the self. Over time, the blaming, self-critical stance toward oneself is substituted with an approach that emphasizes care for well-being, sensitivity, sympathy, distress tolerance, empathy, and nonjudgment (Gilbert, 2009).

Compassion-focused therapy is based on the relationship among three types of emotion regulation systems, drive, safety, and threat. Using compassion-focused approaches enhances the safety or compassion-based soothing system while diminishing the threat-focused emotion regulation system, thereby enhancing the ability to activate (drive) and move in the direction of valued goals. Drawing upon techniques of many empirically supported psychotherapies, compassionate mind training is highly amenable to integration into emotion-focused therapy and CBT protocols.

There is considerable prima facie evidence for the use of compassion-focused therapy in the treatment of psychosis. For example, it has been demonstrated that severity of illness in psychosis often correlates with the intensity of self-criticism and negative interpretations of the self, particularly in the context of complex presentations with comorbid mood and anxiety disorders (Tai & Turkington, 2009). Moreover, among individuals with psychotic disorders, self-criticism appears to herald a risk factor for relapse (Gumley, Birchwood, Fowler, & Gleeson, 2006). Finally, it has been suggested that the distressing hallucinated voices often experienced by individuals with psychosis tend to echo and perpetuate negative dynamics evident in the individual’s everyday life with others (Tai & Turkington, 2009).

Research and support for the effectiveness of compassionate mind training in the treatment of psychosis is growing. Laithwaite and colleagues (2009) found that among a small sample of individuals with psychosis who received a yearlong intervention with integrated compassionate mind training, significant benefits were apparent with respect to measures of social comparison, mood, shame, self-esteem, and overall well-being. Braehler and colleagues (2013) found significant clinical improvements and significant increases in compassion. Notably, significant increases in compassion were associated with decreases in depression and social marginalization ratings. For a description of the application of group CFT for recovery after psychosis, see Braehler, Harper, and Gilbert (2013). For excellent resources on the science and practice of self-compassion, see Germer (2009) and Neff (2011).

Next week we’ll wrap up our series on the integrative treatment protocol for psychosis with discussion of mindfulness for psychosis as well as behavioral activiation. For more information on this groundbreaking approach, check out Treating Psychosis: A Clinician’s Guide to Integrating Acceptance and Commitment Therapy, Compassion-Focused Therapy, and Mindfulness Approaches Within the Cognitive Behavioral Therapy Tradition.

References

Braehler, C., Gumley, A., Harper, J., Wallace, S., Norrie, J., & Gilbert, P. (2013). Exploring change processes in compassion focused therapy in psychosis: Results of a feasibility randomized controlled trial. British Journal of Clinical Psychology, 52, 199–214. doi:10.1111/bjc.12009

Braehler, C., Harper, J., & Gilbert, P. (2013). Compassion focused group therapy for recovery after psychosis. In C. Steel (Ed.), CBT for schizophrenia: Evidence-based interventions and future directions. Chichester, U.K.: Wiley-Blackwell.

Copeland, M. E. (2010). WRAP Plus. West Dummerston, VT: Peach Press.

Germer, C. K. (2009). The mindful path to self-compassion: Freeing yourself from destructive thoughts and emotions. New York, NY: Guilford Press.

Gilbert, P. (1992). Depression: The evolution of powerlessness. Hove, UK: Lawrence Erlbaum.

Gilbert, P. (2009). The compassionate mind: A new approach to life’s challenges. Oakland, CA: New Harbinger Publications.Gilbert et al., 2001

Gumley, A., Birchwood, M., Fowler, D., & Gleeson, J. (2006). Individual psychological approaches to recovery and staying well after psychosis. Acta Psychiatrica Scandinavica, 114, 27.

Laithwaite, H., O’Hanlon, M., Collins, P., Doyle, P., Abraham, L., Porter, S., et al. (2009). Recovery After Psychosis (RAP): A compassion focused programme for individuals residing in high security settings. Behavioural and Cognitive Psychotherapy, 37, 511–526. doi:10.1017/S1352465809990233

Neff, K. (2011). Self-compassion: Stop beating yourself up and leave insecurity behind. New York, NY: William Morrow.

Seligman, M. E. (2002). Authentic happiness: Using the new positive psychology to realize your potential for lasting fulfillment. New York, NY: The Free Press, Simon & Schuster.

Tai, S., & Turkington, D. (2009). The evolution of cognitive behavior therapy for schizophrenia: Current practice and recent developments. Schizophrenia Bulletin, 35, 865–873. doi:10.1093/schbul/sbp080

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While CBT has been practiced clinically for over forty years, it is only recently that structured cognitive and behavioral interventions for psychosis have emerged. CBT for psychosis (CBTp) typically emphasizes fostering a strong, supportive, collaborative therapeutic alliance; providing psycho-education and normalization; developing a cognitive behavioral conceptualization; developing skills or strategies to address stress, barriers, and distress related to experiences such as hallucinated voices or unusual beliefs; utilizing cognitive and behavioral techniques such as cognitive reappraisal and behavioral experiments to diminish the distress associated with positive symptoms; focusing on relapse prevention and recovery; and addressing secondary or comorbid problems such as substance use, anxiety, and depression (Kingdon & Turkington, 1994; Rector & Beck, 2002).

But according to the authors of Treating Psychosis: A Clinician’s Guide to Integrating Acceptance and Commitment Therapy, Compassion-Focused Therapy, and Mindfulness Approaches within the Cognitive Behavioral Therapy Tradition, there are other modalities which can contribute significantly to the treatment of psychosis and should be integrated.

Before discussing acceptance and commitment therapy (ACT), it may be helpful to briefly consider the broader context in which ACT has evolved. Studies examining the mechanism of exposure-based therapies have strongly suggested that the function of thoughts is far more important than their actual content (Barlow, 2002; Wells, 1994). Indeed, the successful integration of mindfulness techniques into clinical treatments such as Linehan’s (1993) dialectical behavior therapy (DBT) and Segal, Williams, and Teasdale’s (2002) mindfulness-based cognitive therapy (MBCT) suggest that the constructs of acceptance, awareness, and cognitive flexibility may have considerable utility in clinical practice. This “third wave” of behavioral and cognitive therapies is particularly sensitive to the context and functions of psychological phenomena, and thus tends to emphasize contextual and experiential change strategies. For these reasons, third-wave therapies may be particularly applicable to the treatment of psychosis.

Central among these third-wave therapies is ACT (Hayes, Strosahl, & Wilson, 1999). From the perspective of ACT, mental health problems are thought to arise when the process of thinking is viewed as seamless with the products of thinking. Through the process of cognitive fusion, thoughts become functionally equivalent with actual events (Ciarrochi, Robb, & Godsell, 2005). For example, in an individual experiencing psychosis, the thought “I am being watched by the police” is evaluated not as simply a thought but rather as functionally equal to actual experiences reflecting the objective reality of being watched by law enforcement officials. Cognitive fusion is harmful in that it fosters avoidance of triggering aversive thoughts (Hayes, Wilson, Gifford, Follette, & Strosahl, 1996). Given that cognitive fusion facilitates both cognitive inflexibility and experiential avoidance that disrupts or impedes moving toward valued goals, ACT seeks to develop patients’ psychological flexibility.

Within ACT, values are the principle drivers behind action, acceptance, and defusion. Values are defined by Hayes, Luoma, Bond, Masuda, and Lillis (2006) as “chosen qualities of purposive action that can never be obtained as an object but can be instantiated moment by moment.” Values are not goals in that they are not things to be attained; rather, they are directions that can be lived out (Eifert & Forsyth, 2005). Defining committed action serves to mitigate the suffering that can be a consequence of cognitive fusion and experiential avoidance. Hayes, Strosahl, and Wilson (2012) describe ACT as involving the processes of accepting, choosing, and acting, or engaging in committed action.

The evidence for ACT being effective in the treatment of psychosis, though limited at this point in time, is generally quite favorable. There is growing evidence that, among individuals affected by psychosis, ACT is effective in reducing the believability of psychotic experiences, reducing depressive symptoms, enhancing mindfulness, and lowering rates of rehospitalization and utilization of health services (Bach & Hayes, 2002; Bach, Hayes, & Gallop, 2012; Gaudiano & Herbert, 2006; Gaudiano, Herbert, & Hayes, 2010; White et al., 2011)

Next week we will continue our exploration of some additional modalities (beyond CBT and ACT) that Wright, Turkington, and their colleagues have drawn from in the development of their integrative protocol for treating psychosis. We’ll discuss positive psychology, compassion-focused therapy, mindfulness, and behavioral activation. Stay tuned!

References

Bach, P., & Hayes, S. C. (2002). The use of acceptance and commitment therapy to prevent the rehospitalization of psychotic patients: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 70, 1129–1139. doi:10.1037//0022006X.70.5.1129

Bach, P., Hayes, S. C., & Gallop, R. (2012). Long-term effects of brief acceptance and commitment therapy for psychosis. Behavior Modification, 36, 165–181. doi:10.1177/0145445511427193Barlow, 2002;

Ciarrochi, J., Robb, H., & Godsell, C. (2005). Letting a little nonverbal air into the room: Insights from acceptance and commitment therapy. Part 1: Philosophical and theoretical underpinnings. Journal of Rational-Emotive & Cognitive-Behavior Therapy, 23, 79–106. doi:10.1007/s10942-005-0005-y

Eifert, G. H., & Forsyth, J. P. (2005). Acceptance and commitment therapy for anxiety disorders: A practitioner’s treatment guide to using mindfulness, acceptance, and values-based behavior change strategies. Oakland, CA: New Harbinger Publications.

Gaudiano, B. A., & Herbert, J. D. (2006). Believability of hallucinations as a potential mediator of their frequency and associated distress in psychotic inpatients. Behavioural and Cognitive Psychotherapy, 34, 497–502. doi:10.1017/S1352465806003080

Gaudiano, B. A., Herbert, J. D., & Hayes, S. C. (2010) Is it the symptom or the relation to it? Investigating potential mediators of change in acceptance and commitment therapy for psychosis. Behavior Therapy, 41, 543–554. doi:10.1016/j.beth.2010.03.001Hayes, Wilson, Gifford, Follette, & Strosahl, 1996

Hayes, S. C., Strosahl, K., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. New York, NY: Guilford Press.

Hayes, S. C., Luoma, J., Bond, F., Masuda, A., & Lillis, J. (2006). Acceptance and commitment therapy: Model, processes, and outcomes. Behaviour Research and Therapy, 44, 1–25. doi:10.1016/j.brat.2005.06.006

Hayes, S. C., Strosahl, K., & Wilson, K. G. (2012). Acceptance and commitment therapy: The process and practice of mindful change (2nd ed.). New York, NY: Guilford Press.

Kingdon, D. G., & Turkington, D. (1994). Cognitive-behavioral therapy of schizophrenia. New York, NY: Guilford Press.

Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York, NY: Guilford Press.

Rector, N., & Beck, A. (2002). Cognitive therapy for schizophrenia: From conceptualization to intervention. The Canadian Journal of Psychiatry, 47, 41–50.

Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2002). Mindfulness-based cognitive therapy for depression: A new approach to preventing relapse. New York, NY: Guilford Press.

Wells, A. (1994). Attention and the control of worry. In G. C. L. Davey & F. Tallis (Eds.), Worrying: Perspectives on theory, assessment, and treatment (pp. 91–114). Oxford, UK: Wiley.

White, R. G., Gumley, A. I., McTaggart, J., Rattrie, L., McConville, D., Cleare, S., & Mitchell, G. (2011). A feasibility study of acceptance and commitment therapy for emotional dysfunction following psychosis. Behaviour Research and Therapy, 49, 901–907. doi:10.1016/j.brat.2011.09.003

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However, given that at least 50 percent of individuals diagnosed with schizophrenia experience persistent and distressing psychotic experiences despite adequate medication management and adherence (Robinson, Woerner, McMeniman, Mendelowitz, & Bilder, 2004), the need for additional treatment strategies is paramount.                                                            

This urgency for novel treatments is all the more pressing when the economic and social costs of psychotic disorders are considered. Although psychotic disorders affect less than 1 percent of the general population, in Canada schizophrenia alone accounts for an estimated CAD$1.12 billion in direct health care and non–health care costs (Canadian Psychiatric Association, 2005). Similarly, a recent review conducted in the UK concluded that the total cost per year of schizophrenia was £8.8 billion. Although less prevalent, costs for affective psychotic disorders were similar at £5.0 billion per year (Kirkbride & Jones, 2011). Finally, a US study examining costs of various chronic illnesses among a Medicaid dataset found that psychosis was the most costly chronic condition to treat per individual on an annual basis (Garis & Farmer, 2002). Costs to treat psychosis on a yearly basis exceeded costs associated with cardiovascular illness and diabetes. Importantly, psychosis was noted to be a contributing factor in approximately 70 percent of the most costly chronic illness co-occurrences. Economic costs aside, psychotic disorders are associated with significant morbidity and mortality and extensive disability in occupational, social, and day-to-day functioning as well as overall quality of life.

Finally, though not often directly considered, the disability associated with psychotic disorders often requires that family members become involved in care. This involvement frequently strains the family’s emotional and financial resources, leading to burnout and other negative impacts on quality of life and psychological well-being. Clearly, it is important to expand treatment approaches and maximize outcome, particularly with individuals persistently distressed by psychotic experiences.

Psychotic experiences, such as hallucinated voices and delusions in addition to difficulties with respect to thought, behavior, and emotion, can be observed transdiagnostically. Delusions are defined as erroneous beliefs that usually involve a misinterpretation of perceptions or experiences (in the Diagnostic and Statistical Manual of Mental Disorders, or DSM–V; American Psychiatric Association, 2013). While delusions can encompass a number of themes, the most frequently reported relate to notions of paranoia and/or persecution—for example, “the CIA is setting me up”—and reference a belief that random events, objects, or behaviors of others are relevant to the individual. Other common delusions include those of a somatic, religious, or grandiose nature. Delusions are frequently, but not always, judged to be bizarre by the clinician. Care must be taken to evaluate a delusional belief in the context of an individual’s cultural norms, practices, and beliefs.

Hallucination is the clinical term to refer to the experience of sensory perceptions without a corresponding external stimulus (American Psychological Association, 2013). Hallucinations are most commonly experienced through the auditory system in the form of voices, but they can be experienced through any sensory modality, including the visual, olfactory, gustatory, and tactile systems. Care must be taken to appropriately contextualize the experience reported by the individual, given that hallucinations can be a normative experience within some cultures. Moreover, hallucinations are broadly experienced by the population under a variety of circumstances.

While schizophrenia is the diagnosis most closely associated with symptoms of psychosis, symptoms of psychosis including delusions and hallucinations are a core feature of a number of different classifications including schizophreniform disorder, schizoaffective disorder, brief psychotic disorder, and delusional disorder. In addition, psychotic experiences can also be a primary feature of mood disorders such as bipolar disorder and, less frequently, major depressive disorder. Moreover, severe forms of post-traumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), body dysmorphic disorder, anorexia nervosa, hypochondriasis, and some personality disorders can present with psychotic features, particularly with respect to insight around the nature and severity of symptoms.

Although traditional notions of psychosis reflect a decidedly categorical approach, Nicola Wright, PhD, and Douglas Turkington, MD—coauthors of Treating Psychosis: A Clinician’s Guide to Integrating Acceptance and Commitment Therapy, Compassion-Focused Therapy, and Mindfulness Approaches Within the Cognitive Behavioral Therapy Tradition—propose that it may be advantageous to conceptualize psychosis along a continuum.

This stance is born from the observation that, when looking at the clinical presentation of individuals with psychotic disorders, it is often the case that the core presenting symptoms reflect exacerbation of psychological, perceptual, or behavioral processes that were present long before the functional impact of these symptoms reached that of a diagnosable mental illness (Linscott & Van Os, 2010). In addition, psychosis-like experiences are prevalent among normative samples, free of serious mental illness (Linscott & Van Os, 2010).

Studies that have sought to determine the prevalence of hallucinations in both normative student samples and nonclinical adult populations have by and large found that a considerable proportion of individuals experience hallucinations at some point in their lives (Beck, Rector, Stolar, & Grant, 2009). For example, it is well documented that auditory, visual, and tactile hallucinations readily occur in healthy individuals during transition from awake and sleep-states and vice versa. In addition, mild sleep deprivation will evoke both auditory and visual hallucinations (Ali et al., 2011). Likewise, the experience of delusion-like ideas or beliefs appears to be fairly common. Notably, a recent review by Linscott & Van Os (2010) concluded that specific psychotic experiences, including both delusions and hallucinations, are three to 28 times more prevalent in the general population than schizophrenia itself.

Taken together, these data strongly suggest that psychotic experiences exist along a continuum, the presence of which does not automatically suggest or confer functional impairment or illness. Indeed, we suggest that psychotic experiences need only be addressed to the extent that they distress individuals and distract them from carrying out lives lived in the service of identified valued directions, such as establishing and maintaining both platonic and romantic relationships, connecting with extended family, maintaining physical health, fostering volunteer work or paid employment, taking time for leisure and relaxation, or pursuing educational opportunities. Wright and Turkington assert that this stance toward psychotic experiences enhances clients’ perceptions of safety in therapy, reduces stigma, and encourages their self-compassion and the forging of a strong therapeutic alliance. This is particularly important given the relatively high incidence of trauma experienced by this population (Schäfer & Fisher, 2011). Indeed, the negative reactions of others toward psychotic experiences as well as the self-stigma around the presence of psychotic experiences themselves often comprise a secondary form of trauma that greatly impedes clinical progress (Bendall, McGorry, & Krstev, 2006).

Next week we will continue our discussion of psychotherapy for psychosis with the protocol presented in the new book by Wright, Turkington, and coauthors, which integrates ACT, compassion-focused therapy, and mindfulness approaches with the traditional framework of CBT.

References

Ali, S., Patel, M., Avenido, J., Bailey, R. K., Jabeen, S., & Riley, W. J. (2011). Hallucinations: Common features and causes. Current Psychiatry, 10, 22–26.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.), Washington, DC: Author.

Beck, A. T., Rector, N. A., Stolar, N., & Grant, P. (2009). Schizophrenia: Cognitive theory, research, and therapy. New York, NY: Guilford Press.

Bendall, S., McGorry, P., & Krstev, H. (2006). The trauma of being psychotic. In W. Larkin & A. P. Morrison (Eds.), Trauma and psychosis: New directions for theory and therapy (pp. 58–74). New York, NY: Routledge.

Canadian Psychiatric Association. (2005). Clinical practice guidelines: Treatment of schizophrenia. Canadian Journal of Psychiatry, 50(S1), 7s–57s.

Garis, R. I., & Farmer, K. C. (2002). Examining costs of chronic conditions in a Medicaid population. Managed Care, 11(3), 43–50.

Kirkbride, J. B., & Jones, P. B. (2011). The prevention of schizophrenia—What can we learn from eco-epidemiology? Schizophrenia Bulletin, 37(2): 262-271.

Linscott, R. J., & van Os, J. (2010). Systematic reviews of categorical versus continuum models in psychosis: Evidence for discontinuous subpopulations underlying a psychometric continuum—Implications for DSM–V, DSM–VI, and DSM–VII. Annual Review of Clinical Psychology, 6, 391–419. doi:10.1146/annurev. clinpsy.032408.153506

Robinson, D. G., Woerner, M. G., McMeniman, M., Mendelowitz, A., & Bilder, R. M. (2004). Symptomatic and functional recovery from a first episode of schizophrenia or schizoaffective disorder. American Journal of Psychiatry, 161, 473–479. doi:10.1176/appi.ajp.161.3.473

Schäfer, I., & Fisher, H. L. (2011). Childhood trauma and posttraumatic stress disorder in patients with psychosis: Clinical challenges and emerging treatments. Current Opinion in Psychiatry, 24, 514–518. doi:10.1097/ YCO.0b013e32834b56c8

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According to Broderick, adolescence is a time of unique possibilities and challenges in development. Research has revealed dramatic transformations in the adolescent brain that specifically relate to education and learning. The adolescent brain undergoes the process of rewiring itself, depending on what is learned and experienced. This stage of reorganization may be particularly sensitive to inner and outer experiences related to emotions and social relationships (Blakemore, 2008).

• In adolescence, changes in the brain mainly occur in the frontal and parietal corticles, which are the site of executive functions, a general term used to describe higher-order cognitive processes (Blakemore & Choudhury, 2006).
• Myelination of the frontal cortex, which allows for smooth and efficient processing of information, proceeds continuously over the course of adolescence but is not complete until early adulthood. During adolescence, the creation and myelination of new synaptic connections occurs, along with the pruning of unused, unpracticed connections. These activities are most pronounced in the prefrontal cortex, located right behind the forehead—which plays a role in self-control, judgment, and emotion regulation—and in the temporal lobes, which serve language functions and contribution to emotion regulation (Sawyer et al., 2012; Casey, Giedd, & Thomas, 2000; Sowell, Thompson, & Toga, 2007).
• Because the adolescent brain is, in many ways, rewiring itself depending on what is learned and experienced, this stage of synaptic reorganization may be particularly sensitive to inner and outer experiences related to emotions and social relationships (Blakemore, 2008).
• In the case of learning, mild stress can enhance memory, but chronic or excessive stress can damage parts of the brain that are critical for new learning and memory consolidation (Sapolsky, 2004).

At the same time, risk-taking behavior among adolescents is at an all-time high. But the propensity toward risky behavior is not sufficiently kept in check by a well-functioning internal monitor (prefrontal cortex), which researcher JoAnne Dahl (2004) describes as “turbo-charging the engines of a fully mature car belonging to an unskilled driver.” The pattern of neurobiological changes that occurs in adolescence may make adolescents particularly sensitive to distress during this period (Walker, 2002), and many researchers now consider adolescence to be a stress-sensitive period of development (Steinberg, 2008).

• Compared to other stages of the lifespan, the changes in hormone levels that occur during adolescence are the most rapid (Fataldi et al., 1999).
• In addition to increases in pubertal sex hormones, greater activation of the HPA axis has also been demonstrated. Recent studies have found that levels of cortisol rise gradually through middle childhood and increase rapidly around age thirteen (Walker & Bollini, 2002).
• Studies of adults have consistently linked increases in HPA reactivity, as measured by cortisol increases, with unipolar and bipolar disorders, schizophrenia, and posttraumatic stress disorder (Müller, Holsboer, & Keck, 2002; Post, 2007; Walker & DiForio, 1997).
• Some evidence suggests a similar pattern for adolescent disorders, notably depression (Birmaher & Heydl, 2001; Goodyer, Park, Netherton & Hebert, 2001). Both hormonal changes and maturation of the HPA axis appear to influence how the brain gets reorganized (Romer & Walker, 2007; Walker, Sabuwalla, & Huot, 2004).

Today’s adolescents also face a host of environmental challenges that can threaten their social and emotional well-being, including:

• The poor fit between developmental needs and the structure and curricula of schools (Eccles, 2004)
• A decline in academic orientation and motivation starting in the early adolescent years (Gutman, Sameroff, & Cole, 2003)
• Increasing psychological separation from parents (Darling, Cumsille, & Martinez, 2008)
• Increasing susceptibility to peer influence (Sim & Koh, 2003)
• Pressures of romantic relationships (Collins, 2003)
• Participation in antisocial or risky behaviors (Reyna & Farlet, 2006)

Heavy exposure to media also presents a significant challenge to today’s teens. Media messages serve as standards for social comparison that may undermine self-esteem, mold expectations for normative behavior, and amplify values that may be at odds with those of families and communities (Comstock & Scharrer, 2006). Research in this area has shown that:

• Increases in feelings of distress in early adolescence are largely attributable to increases in depressed mood (Garber, Keiley, and Martin, 2002; Hammen & Rudolph, 2003) and conflicts with parents (Larson & Richards, 1994; Laursen & Collins, 1994).
• Declines in positive emotionality have also been reported in adolescence (Collins & Steinberg, 2006), and the onset of depression is occurring at younger and younger ages (Cross-National Collaborative Group, 1992).
• A 1993 report by the American Academy of Pediatrics Committee on Psychosocial Aspects of Child and Family Health (2001) that provides a list of threats to adolescent well-being was recently updated to include school problems (including learning disabilities and attention difficulties), mood and anxiety disorders, adolescent suicide and homicide, firearms in the home, school violence, drug and alcohol abuse, HIV, and AIDS; and the effects of media on violence, obesity, and sexual activity were called “new morbidities.”

The sheer number of challenges that adolescents face in navigating this developmental stage may overwhelm their available cognitive and emotional resources, especially for those who have experienced less-than-optimal conditions in infancy and childhood. Adolescence is a sensitive period for emotional development, and the onset of many mental health problems such as depression, anxiety, eating disorders, substance abuse, and schizophrenia during adolescence highlights the need to take the well-being of youth very seriously (Paus, Keshavan, & Giedd, 2008). While research suggests that the adolescent brain is vulnerable to permanent stress-related alterations in the context of pubertal neuroplasticity, this period also can be a time for interventions and opportunities to reduce or reverse the adverse effects accumulated from earlier insults (Romeo & McEwen, 2006).

References

American Academy of Pediatrics Committee on Psychosocial Aspects of Child and Family Health. (2001). The new morbidity revisited: A renewed commitment to the psychosocial aspects of pediatric care. Pediatrics, 108(5), 1227–1230.

Birmaher, B., & Heydl, R. (2001). Biological studies in depressed children and adolescents. International Journal of Neuropsychopharmacology, 4(2), 149–57.

Blakemore, S. J. (2008). Development of the social brain during adolescence. Quarterly Journal of Experimental Psychology, 61(1), 40–49.

Blakemore, S. J., & Choudhury, S. (2006). Development of the adolescent brain: Implications for executive function and social cognition. Journal of Child Psychology and Psychiatry, 47(3–4), 296–312.

Casey, B. J., Giedd, J. N., & Thomas, K. M. (2000). Structural and functional brain development and its relation to cognitive development. Biological Psychology, 54, 241–257.

Collins, W. A. (2003). More than myth: The developmental significance of romantic relationships during adolescence. Journal of Research on Adolescence, 13(1), 1–24.

Collins, W. A., & Steinberg, L. (2006). Adolescent development in interpersonal context. In N. Eisenberg (Vol. Ed.), W. Damon & R. M. Lerner (Series Eds.), Handbook of child psychology: Vol. 3—Social, emotional, and personality development (6th ed., pp. 1003–1067). Hoboken NJ: John Wiley and Sons.

Comstock, G., & Scharrer, E. (2006). Media and popular culture. In K. A. Renninger & I. E. Sigel (Vol. Eds.), W. Damon & R. M. Lerner (Series Eds.), Handbook of child psychology: Vol. 4—Child Psychology in practice (6th ed., pp. 817–863). Hoboken, NJ: John Wiley and Sons.

Cross-National Collaborative Group (1992). The changing rate of major depression: Cross-national comparisons. Journal of the American Medical Association, 268(21), 3098–3105.

Dahl, R. E. (2004). Adolescent brain development: A period of vulnerabilities and opportunities. Annals of the New York Academy of Sciences, 1021, 1–22.

Darling, N., Cumsille, P., & Martinez, M. L. (2008). Individual differences in adolescents’ beliefs about the legitimacy of parental authority and their own obligation to obey: A longitudinal investigation. Child Development, 79(4), 1103–1118.

Eccles, J. S. (2004). Schools, academic motivation, and stage-environment fit. In R. M. Lerner & L. Steinberg (Eds.), Handbook of adolescent psychology (2nd ed., pp. 125–153). Hoboken, NJ: John Wiley and Sons.

Fataldi, M., Petraglia, F., Luisi, S., Bernardi, F., Casarosa, E., Ferrari, E., Luisi, M., Saggese, G., Genazzani, A. R., & Bernasconi, S. (1999). Changes of serum allopregnanolone levels in the first 2 years of life and during pubertal development. Pediatric Research, 46(3), 323–327.

Garber, J., Keiley, M. K., & Martin, C. (2002). Developmental trajectories of adolescents’ depressive symptoms: Predictors of change. Journal of Consulting and Clinical Psychology, 70(1), 79–95.

Goodyer, I. M., Park, R. J., Netherton, C. M., & Herbert, J. (2001). Possible role of cortisol and dehydroepiandrosterone in human development and psychopathology. British Journal of Psychiatry, 179, 243–249.

Gutman, L. M., Sameroff, A. J., & Cole, R. (2003). Academic growth curve trajectories from 1st grade to 12th grade: Effects of multiple social risk factors and preschool child factors. Developmental Psychology, 39(4), 777–790.

Hammen, C., & Rudolph, K. D. (2003). Childhood mood disorders. In E. J. Mash & R. A. Barkley, Child Psychopathology (2nd Ed., pp. 233–278). New York: The Guilford Press.

Larson, R., & Richards, M. H. (1994). Divergent realities: The emotional lives of mothers, fathers, and adolescents. New York: Basic Books.

Laursen, B., & Collins, W. A. (1994). Interpersonal conflict during adolescence. Psychological Bulletin, 115(2), 197–209.

Müller, M., Holsboer, F., & Keck, M. E. (2002). Genetic modification of corticosteroid receptor signalling: Novel insights into pathophysiology and treatment strategies of human affective disorders. Neuropeptides, 36(2–3), 117–131.

Paus, T., Keshavan, M., & Giedd, J. N. (2008). Why do many psychiatric disorders emerge during adolescence? Nature Reviews Neuroscience 9(12), 947–957.

Post, R. M. (2007). Kindling and sensitization as models for affective episode recurrence, cyclicity, and tolerance phenomena. Neuroscience and Biobehavioral Reviews, 31(6), 858–873.

Reyna, V. F., & Farley, F. (2006). Risk and rationality in adolescent decision making: Implications for theory, practice, and public policy. Psychological Science in the Public Interest, 7(1), 1–44.

Romeo, R. D., and McEwen, B. S. (2006). Stress and the adolescent brain. Annals of the New York Academy of Sciences, 1094, 202–214.

Sapolsky, R. M. (2004). Why zebras don’t get ulcers (3rd ed.). New York: Henry Holt and Company.

Sawyer, S. M., Afifi, R. A., Bearinger, L. H., Blakemore, S. J., Dick, B., Ezeh, A. C., & Patton, G. C. (2012). Adolescence: A foundation for future health. Lancet, 379(9826), 1630–1640.

Sim, T. N., & Koh, S. F. (2003). A domain conceptualization of adolescent susceptibility to peer pressure.

Journal of Research on Adolescence, 13(1), 57–80.

Sowell, E. R., Thompson, P. M., & Toga, A. W. (2007). Mapping adolescent brain maturation using structural magnetic resonance imaging. In D. Romer & E. F. Walker (Eds.), Adolescent psychopathology and the developing brain: Integrating brain and prevention science (pp. 55–84). New York: Oxford University Press.

Steinberg, L. (2008). A social neuroscience perspective on adolescent risk-taking. Developmental Review, 28, 78–106.

Walker, E. F. (2002). Adolescent neurodevelopment and psychopathology. Current Directions in Psychological Science, 11(1), 24–28.

Walker, E., & Bollini, A. M. (2002). Pubertal neurodevelopment and the emergence of psychotic symptoms. Schizophrenia Research, 54(1), 17–23.

Walker, E. F., & Diforio, D. (1997). Schizophrenia: A neural diathesis-stress model. Psychological Review, 104(4), 667–685.

Romer, R., & Walker, E. (Eds.) (2007). Adolescent psychopathology and the developing brain: Integrating brain and prevention science. New York: Oxford University Press.

Walker, E. F., Sabuwalla, Z., & Huot, R. (2004). Pubertal neuromaturation, stress sensitivity, and psychopathology. Development and Psychopathology, 16(4), 807–824.

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