Narratives in Transformation in Psychosis. By Isabel Clarke with Katie Mottram, Satyin Taylor and Hillary Peg.

Introduction

Narrative is powerful. It creates selves. It creates cultures. It weaves the context of our lives and experiences. Where those experiences lead beyond consensual reality, as with both the psychotic and mystical, the narrative that contextualizes them is particularly striking. Our society is inclined to pathologize this facet of human experience. Satyin and Katie, whose accounts follow are, like me, involved in developing and running the Spiritual Crisis Network, an organization that offers a hopeful and a spiritual narrative for those going through disturbing and destabilising periods in their life. Hilary is in sympathy, and an important contributor to a supportive yahoo email list with the same theme. Their narratives illustrate how even the darkest of times can herald transformation. My own interest in this is as a clinical psychologist with over twenty years practice in psychiatric rehabilitation, and for the last ten years working in acute mental health services. Honouring the narratives brought by the service users and developing a therapeutic approach that incorporates its transformative potential is central to my approach.

All three personal contributions describe major breakdowns involving the psychiatric services. For Satyin and Hilary this included significant hospitalization. Satyin and Katie now see their ‘episodes’ as behind them and are forging new lives with confidence. Hilary is still recovering from her last, most disturbing, episode and for her there is a sense that the journey is not finished. Two of the contributors were diagnosed at different times as suffering from schizophrenia or bipolar disorder. Katie has never received a formal diagnosis. However, the approach described in this chapter is not diagnosis specific; it has been put to the test over 10 years in NHS-based mental healthcare (mostly inpatient) and with the full range of presentations expected in such a service.

All three contributors regard their experiences as ultimately narratives of transformation rather than of illness. We are passionate about offering the perspective described here to others who are going through the same, potentially including anyone whose life crisis results in their losing touch with consensual reality, or whose vulnerability means that they exist permanently in that state and who are customarily given a psychiatric diagnosis of psychosis.  However, we do recognise that not everyone will agree with this approach, and accept that, in the case of individuals who have long adapted to the psychosis it is likely that potential for transformative growth has been lost.

I will first let Katie, Satyin and Hilary speak for themselves, then draw together some of the characteristics of their narratives into a framework that helps to make the link between opening to another dimension and transformation. I conclude with significant current research pointing those of us working in mental health towards a new and more positive narrative, and how service developments can benefit from this learning.

Katie

I grew up with a skewed subconscious belief that I was only worthy of living if I was of help to others because my mum had attempted suicide when I was born, and then again when I was seventeen. I felt somehow responsible and as soon as I was old enough, I threw myself into mainstream psychiatry to protect myself with knowledge to prevent ‘madness’ happening to me. The more I learned, the more confused I became, as what I was learning about didn’t feel authentic with my soul. Battling to understand resulted in years of feeling inadequate, depressed, and a heavy sense that in order to fit in with a reductionist approach, I had to pretend to be someone I was not

Holding a ‘professional’ diagnostic view of psychosis and having witnessed my mother being sectioned and given electroconvulsive treatment (she had claimed to be spirit possessed, believing herself to be a ‘healer’) I was petrified that the same would happen to me. My mum had been diagnosed with schizoaffective disorder and was now suffering badly from the side effects of medication.  

In 2008 I could no longer maintain my façade of being ‘okay’ and experienced my own mental breakdown. Various traumatic life events took their toll on my already fragile sense of self and I made a serious attempt on my own life. Nothing made sense and living seemed futile. Petrified, knowing I was following in my mother’s footsteps, I avoided seeking help, knowing where that would lead. I worked in mental healthcare yet I could not trust the system to provide the support I so desperately needed; it made me feel like a hypocrite.

Then, in March 2012 my belief system about mental illness, the world and my place in it changed literally overnight. During a meditation I experienced a profound breakthrough; the awareness being a soul, I awoke from a state of merely existing as someone who had a mountain of self- doubt to a sense of knowing that I could be anyone I wanted to be. I could reclaim the control of my life I had been longing for but which before that moment I never believed I could have. An absolute sense of pure peace washed over me and I felt that I was totally connected to everything and everyone in the world. I had no sense of anger or fear; everything was taken over by clarity of perspective, acceptance and understanding. At that moment every piece of the jigsaw of my life made complete sense and I had not one regret, I just knew that every crisis had happened to bring me to this moment of strength. My mind had been blessed with a glimpse of another level of consciousness and it would never be the same again. My soul knew that I’d had access to the Universal consciousness, and at this time could freely to communicate with spirit. It was an ineffable, amazing experience.

The irony was that having worked within the mental health system for over twelve years, my educated ‘logical’ brain told me I was psychotic and having delusions of grandiosity. My energy levels at the time were unbounded, and I also feared that I was manic. This chasm of comprehension between my soul and my mind threw me into panic and confusion. Continuing my ‘normal’ daily life without speaking about what I was experiencing at a deeper level was a real challenge, but I feared that if I told anyone who I worked with about my experience, I might end up being hospitalised.

At the same time I suddenly realized that my mum too had been experiencing a spiritual awakening, but not understanding it. The resulting cycle of crisis was aided by myself through my part in getting her sectioned, unable to understand her behaviour at the time. She  had spoken about getting ‘messages’ from spirit and being able to predict the future, and I had brushed this off as mad ramblings. Now I recognized our experiences as similar.

Over the last two years I have spoken openly to Mum about spirituality, and acknowledged her own interpretation of her experiences. After more than thirty years of living in an emotionally frozen state, this different narrative has been the only thing that is gradually helping to bring Mum back on the road to recovery. She is no longer locked into a negative belief pattern that she is crazy and worthless. There have been no other changes to her treatment, and the difference in her is astonishing.

Now my mum and I very much see facing the pain as an intrinsic part of our evolutionary process. I consider myself to be hugely lucky. Despite my doubting logical brain, I had the strength of character to listen to my soul, which led me to find a network of people in the UK Spiritual Crisis Network who understood the phenomena of spiritual emergence. With the stability of this conceptual framework to make sense of my experiences and allow natural evolution and integration was like coming home - the opposite of seeing psychosis as a destructive illness. I am now more able to be a ‘silent witness’ to my emotions, rather than letting them control me, and I have a much more positive belief system. I know that I am on a life-long journey of learning, one I enjoy and appreciate.  

This positive frame of reference in which to make sense of my experience has both  helped me and given me the  belief that I  can  make a positive difference to others. I am now working in collaboration with my local NHS Trust on their spirituality strategy, and am able to provide valuable insight into this different perspective I am writing a memoir to inspire hope in others who may be suffering. My ultimate mission is to help transform the mental health system into one that is more positive, progressive and open-minded.

Satyin

Growing up nominally Christian and an apparently natural pacifist, after introverted teenage years I blossomed socially at University in London. I also started to smoke cannabis, enjoying my own company without a sense of missing out and steeping myself more and more deeply in the music I loved. It also seemed to open me up in an unexpected way.  

During the second year of my psychology degree in 1994, aged 20, I had a 'prodromal' couple of weeks of seemingly increased functioning when things apparently ‘made sense’. This culminated one evening when I found myself writing a ‘stream of consciousness’, for exactly four hours  Memorably the word ‘Nirvana’ appeared unbidden very strongly in my mind. I was clear something different or odd was going on, so turned to the question of the existence of God, saying to myself ‘God if you exist give me a sign’. News of the suicide of Kurt Cobain of the band Nirvana, unusual confidence in acquiring cannabis and further coincidences led to my declaring to the household:  ‘I think I’m Jesus’. I remember trying to convince them that something significant was happening spiritually in the universe, pointing to a TV soap opera on in the background as evidence of this.  

The following days brought a series of many fascinating experiences and 'coincidences'. Increasingly my mind was racing; I was seeing things differently and recognized the possibility of 'illness' from my abnormal psychology studies. I certainly did require support, and with encouragement I went to my University General Practitioner and was repeatedly assessed until I found myself tucked up in bed, informally admitted to an adult acute mental ward.  

Whilst my unusual ideas were cause for concern, my family found it tremendously distressing to see me so sensitive to the antipsychotic medications being tried out on me. Side effects meant one day my Dad having to help me to walk; I was experiencing lock-jaw, slurred speech, and major stiffness - basically a dribbling wreck. At one time, my father cried, wondering if he would ever get his son back to normal.

Yet I've never felt anger towards the system, I knew it was doing what it thought best.

None of the antipsychotics 'took away' the unusual experiences, the ‘coincidences’ or targeted the 'grandiose' way I had made sense of my experience. Whether things shifted naturally, or because of the Lithium that was eventually prescribed is unclear.    

During my lengthy hospitalization I had been aware of positives: a new openness to Nature, unaccustomed skill at golf putting and spontaneous compassion. Alas, all dropped away as I got ‘well’. Spiritual grandiosity was replaced by cringing embarrassment after discharge. I came down with a bump during a depressed summer, followed by successful autumn re-entry into academic life with completion of my degree and avoidance of cannabis. I did not conceal my story - a helpful lack of repression here - but I felt that what had been a tremendously significant time for me was now written off as simply an illness. I moved from volunteering on the ward where I had been a patient to an Occupational Therapy Assistant post in 1997.

In 2000 I was lucky enough to find out about and get support to attend the first of two conferences on ‘Psychosis and Spirituality’ (Clarke 2010 p.3) , affording the opportunity to meet others who had had similar experiences as well as open-minded professionals who were interested in meaningful ways of understanding unusual experience. This initiated a period of revaluation of my formative meaningful experiences rather than cutting them off as illness as usually happens.

I successively got into yoga, meditation and Buddhism. In 2004 on a Buddhist retreat, confident I would not be troubled by such strong experiences again, I saw a woman with whom I felt a most unusual tangible energy connection across the shrine room. When we spoke there seemed an instant strong connection, and we acknowledged this. I went to bed thinking ‘I've met my partner, what was all the fuss about, that was straightforward.’

However, this very significant relationship brought with it experiences like those of ten years before: sleeplessness, strong energy rising and needing to write. I snapped out of the speeding mind into a sense of expansive peace and began trying to make sense of it. Having been going to Buddhist classes and retreats for nine years I jumped to a conclusion; given the difference in consciousness I was experiencing, I announced to my partner to be that I must be 'enlightened'!

I was lucky enough to get support in the form of help from people who recognised the concept of Spiritual Emergency, who gave me pertinent advice and validation. It was important that I could find a way to make sense of, and integrate, the experience. I knew that this was a deeply meaningful experience for my personal growth. My knowledge of Buddhism and ‘The Hero’s journey’ also gave me support and a positive conceptualisation of what I was going through.

As I write this narrative of my transformation, I am travelling across Europe on sabbatical from my NHS role working with psychosis, to begin a four month intensive ordination retreat. It is my chosen way to build the optimal conditions for gaining insight into the true nature of ‘reality’. As a result of my experiences, the challenge of transcending the ‘conditioned mind’ is no longer an abstract concept. I know other modes of operating are possible.

Hilary

I have had three psychoses or episodes of connecting beyond myself. The first occurred soon after my mother died and at a time when my sister was pronounced to have terminal cancer. One day in the garden a voice spoke through me saying ‘my name is Al Alal, I am from the Institute of Joseph of Arimathea and I have come to help you heal your sister’. In the end Al Alal told me he was in error and that he was being taken to another part of the spirit world. From that point, things started getting bizarre. I was informed that I was attached to an aeroplane flying overhead by a chord. My husband called the doctor and a voice speaking through me said ‘I am a charismatic pilot, will you please send this woman to hospital’. From the doctor’s perspective, it was me who was talking but as far as I was concerned it was not my voice. I spent about a month in the hospital being visited by a variety of spirits. A spirit named Pelegeia did automatic writing with me. The episode resolved when some ‘spirit doctors’ arrived and told me to release the spirits attached to me by letting them jump off my tongue into a glass of water.

Before I had this experience, which was the most extraordinary thing that had ever happened in my life, I was what I would term a middle-of-the-road Christian. Now I feel open to a whole lot of beliefs, channelling, Near Death Experiences, spirit attachment, and reincarnation. Rather than seeing it as an illness, I experienced this time as an awakening to new possibilities.

Two years later I had another episode in which I was told by voices (not my own) that I was to press the button that would set off all the nuclear arsenals in the world. I heard other voices doubting that I could do such a thing, but they were informed ‘I had been trained’. I felt my body being moved. I was told I was the second coming of Jesus. I met God and played word games with him. I was told that I had been made into a perfect human being, though life would knock the corners off, and that a tape was being made of my life. I was told that everything in life had been perfectly planned and that everyone would be rewarded or punished according to their deserts. When I later read about karma I was amazed at the similarity. I was also asked what I wanted to do with my life and I said I wanted to stay exactly where I was, among people with mental health problems. I even remember ordaining myself.

These experiences, dismissed as meaningless by the hospital staff, inspired me to communicate my new perspective and heralded a period when I became very active. I flew up to Dundee to a conference on spirituality in mental health and following this attended two ‘Revisioning Mental Health’ conferences in Stroud that marked the beginning of the Spiritual Crisis Network. I had come across the Royal College’s Spirituality and Psychiatry Special Interest group and corresponded with Dr Alan Sanderson about the nature of spirit release. I was so intrigued by this I trained in hypnotherapy and went to two conferences in London and an introductory workshop on releasing spirits. I even got my local council to part fund my trip.

I undertook research into the work of chaplains in mental health services, gaining an MSc. A group of us put on a conference at our local trust on ‘Spirituality and Mental Health’. I found a psychiatrist who would help me wean myself off psychiatric medication. I was becoming an evangelist for spirituality and psychosis. It was only then that I discovered the darker side, and the potential dangers of being open to this other way of experiencing.

In a third episode, I was told that I had discovered the truth about the universe and would be taken to a higher plane. Then I found myself on the floor being told to come back down to Earth and take human form quickly as I had nearly ‘blown my cover’. I assumed I was an alien of some sort. I believed that my husband had married me in order to protect the public from discovering my identity. This was a frightening psychosis in which I was convinced that a terrorist group had penetrated my brain and were about to kill me. I believed the bungalow I was living in had been burned to the ground and the room I was in had been transported to another part of the universe. I had come off my medication at this time and I decided to go back on it to prevent further events happening.

For me, these episodes have been, in part, a transformative experience. While it has widened my belief system and opened me to new vistas, having a bad ‘trip’ was plain frightening. However, I do not regret them. After two deaths in close proximity, leaving me without a family, something needed to ‘give’.

I am still working with my local Mental Health Trust highlighting the link between spirituality and psychosis but I have lost the confidence to travel and never did take up spirit release therapy. This loss of confidence may be temporary, who knows, for I am on a journey. In my own mind, my faith in something bigger than myself has been enhanced and I am quite ready to believe that I had both a psychosis and a spirit attachment.

Wider Perspectives

These accounts have elements in common that point to a way of making sense of a breakdown; of departure from shared reality and problems with functioning, but which honours its transformative potential. All three can be recognized as belonging to a group of people that may be referred to as ‘high schizotypes’. This is an important concept when seeking to normalize anomalous experiencing. Schizotypy is here understood as a dimension of normality, and is to be distinguished from schizotypal personality disorder, a diagnosis which has little bearing on this concept. As used here, schizotypy signifies ease of access to 'non-ordinary experiencing', and aims to bring such experiences (which may attract the label of 'psychosis') within the compass of normality. 

The body of schizotypy research conducted over decades by Claridge and his collaborators (Claridge 1997, 2010) explores the dimension of human experience represented by openness to the unusual and the anomalous that lie beyond consensual reality. Though the predominant association for this vulnerability is psychotic breakdown, schizophrenia etc., the body of research makes a clear association with the valued attributes of creativity and spirituality as well. The fact that Katie’s mother was diagnosed as psychotic underlines that this trait does have a physical, heritable, substrate, which nevertheless does not need to be understood in a reductionist way. Katie was able to extend her re-evaluation of the experience to her mother. These experiences opened horizons to take in previously excluded spiritual perspectives, involving stepping out of a normal, restricted, sense of self into a place where the self was less defined, and sometimes felt to be supremely important. Hilary thought she was an alien on a mission and Satyin thought he was Jesus or had become enlightened. The lack of a safe boundary can bring fear, destabilisation and danger as Hilary experienced most strongly in her third episode, but equally it can open the way to heightened perception and attunement to synchronicities.

A sense of constriction or incompleteness prior to this opening is a common theme. Satyin had been unconfident. Katie had felt responsible for her mother’s woes and Hilary had experienced multiple losses. The role that psychotic breakdown played in resolving their various difficulties can be seen in terms of Mike Jackson’s ‘problem solving’ model of psychosis (Jackson (1997, 2010). Jackson argues that this other dimension of experience opens up when normal life has reached an impasse and becomes a way forward particularly for high schizotypes. This can enable the individual to draw on resources that were previously beyond their reach, hence the transformative potential. However, the need to protect against the vulnerability this engenders can lead to a vicious circle of getting lost in a psychotic world and becoming trapped in pathology leading to isolation.

I have written elsewhere on how these phenomena can be understood in terms of neural processing (Clarke 2008, 2010a, 2013). In summary, the more recent evolutionary verbal faculty serves to filter our perceptions; by default, the rest of the brain organizes relationship, emotion and experience. Together they share control, with a capacity to desynchronize in certain circumstances, but neither is ‘the boss’ (Teasdale & Barnard 1993), (Barnard 2003). According to Teasdale and Barnard’s Interacting Cognitive Subsystems model of cognitive architecture, the verbal, propositional subsystem gives us our separateness and grasp of detail; the default, implicational subsystem manages relationship and emotion. When the implicational dominates, we lose the certainty of individual selfhood, leading to confusion about the boundaries of the self. With no means of monitoring between the genuine and illusory, this state can lead to persecutory synchronicities and false certainties. However, it can also open a person to genuine connection with God and the universe so characteristic of mystical experience. In contrast to everyday living, which is ruled by the logic of either/or, this state is governed by the paradoxical logic of both/and, as religious writings the world over have reflected.

While the above could be regarded as speculative, recent lines of research suggest a line of continuity between psychosis and psychosis-like experiences that never progress to diagnosable illness (Linscott & van Os 2013, van Os et al. 2009). Linscott and van Os conclude: ‘Emphasis on symptomatology (actual experience as opposed to disorder class) would reduce the risk of stigmatization and facilitate the identification of proximal antecedents of distress, thereby providing a more salient, amenable target for monitoring and intervention’ (Linscott & van Os 2013 p.1145).

Research into symptoms experienced positively (Jackson, Hayward & Cooke 2010, Jenner et al. 2008, Sanjuan et al. 2004) sheds further light. Jackson, Hayward & Cooke (2010, P.487) conclude that: ‘Promoting a positive self-concept and connecting with communities who value and accept voice-hearing experiences may be particularly important.’ The most significant body of research is the ‘need for care’ strand in which Emmanuelle Peters (Institute of Psychiatry) is prominent. Comparing groups of people with exactly comparable ‘symptoms’, it has been shown that the outcome is better where people have found a non-medical and essentially benign way of making sense of their anomalous experiences (Brett, Heriot-Maitland, McGuire & Peters (2013), Brett, Johns, Peters & McGuire (2009), Brett, Peters, Johns et al. (2007), Heriot-Maitland, Knight & Peters (2012), Marks, Steel & Peters (2012). The overall conclusion of these studies reinforces the importance of a social and cognitive context that provides hopeful and non-stigmatizing meaning for such experiences, even where they are very distressing and severely affect functioning. Spiritual conceptualisations come out particularly well. Taken together with epidemiological evidence showing that traditional societies with a less rigidly medical approach to schizophrenia show better outcome (Warner 2007, 2004), this evidence should occasion reflection for those of us who work in mental healthcare.

The concern of this chapter has been with a way of experiencing open to all human beings but more often accessed by high schizotypes. This has been the territory of saints and mystics; they too encountered terror as well as ecstasy, their experiences were frequently preceded by illness or transition, and their day-to-day functioning was often supported by a community when compromised. Many of these individuals were looked up to for the wisdom they derived from their journey (Clarke 2008 Ch.6). This way of experiencing can also arise in more profoundly disabling forms of major mental illness not identified in the examples given here. In such cases medicalization cannot always be avoided, or the stigma that may attach, but it is still possible to find ways of promoting a positive self-concept amidst the experience and to offer hope and meaning. Those who enter this other way of experiencing can easily lose their ‘selves’. In this magical and dangerous liminal state, anything is possible, and it can go either way. The research quoted above, and the experience of Katie, Satyin and Hilary illustrate how the course of the ‘illness’ is powerfully influenced by the way in which people make sense of such experiences, in turn shaped by those around them.

As the psychologist in an acute service (hospital and crisis resolution and home treatment) I have been concerned to make use of this potential for growth and healing. Cognitive Behaviour Therapy (CBT) for psychosis can embrace mindfulness as a way of enabling the individual to gain distance between themselves and disturbing experiences. A key factor promoting a benign outcome is the ease with which the individual can move backwards and forwards at will between ‘unshared’ (psychotic) and ‘shared’ reality. The skill of mindfulness can facilitate this movement because it can create distance between the experience and the experiencer. The growing evidence for the efficacy of CBT for psychosis by incorporating mindfulness demonstrates this (Chadwick et al. 2009, Dannahy et al. 2011).

I therefore developed a programme for delivery within the Acute service called ‘The What is Real and What is Not’ group (Clarke 2010b, 2013), which takes as its norm the human facility to access apparent ‘other realities’. We started by looking at the spectrum of openness to unusual experiencing (schizotypy) in its positive and negative aspects. By exploring recognition of ‘unshared’ as opposed to ‘shared’ reality, it was possible to honour the positive aspects of vulnerability to this state, at the same time facing up to its problems and dangers. Spiritual aspects could be validated while also sounding a note of caution. Pointing out that ‘unshared reality’ is governed by a logic of ‘both/and’ (as explained above) proved useful in dealing with convictions of specialness. Indeed, this concept was usually understood quite easily by the group.

Brainstorming with the participants on the characteristics of ‘shared’ and ‘unshared’ reality usually produced ‘frightening and lonely’ but ‘buzzy’ for the unshared state, whereas shared reality was identified as safer, more controllable but ‘boring’. This perspective provided the foundation for encouraging participants face up to unshared reality and to learn skills such as mindfulness to manage it.

Once the group were prepared to look more dispassionately at their experiences, and let go both of the desire to ‘seal over’ and dismiss them or to accord them too great importance, they were in a better place to learn the skills to manage them. The role of mindfulness in enabling someone to gain distance and manage the necessary transition from ‘unshared’ to ‘shared’ reality has already been mentioned. Arousal management is another key skill. Symptomatic experiences are more accessible at times of high stress and arousal, when simple techniques such as relaxation breathing can be of benefit. Less recognized is the role of low arousal in increasing vulnerability to symptomatic experiences; hypnogogic states and the popular pastime in hospitals of looking at the TV without really watching it, need to be addressed by simple, behavioural correctives.

Once participants start to feel more on top of the situation, the idea that their psychosis might have some learning for them, the possibility of resolution of past trauma and conflict and looking out for new growth, can all be discussed. The manual for this group work is available online.

My current job in my NHS Trust concerns evaluating and re-ordering acute services on a holistic and therapeutic basis (for the pilot phase, see Durrant et al. 2007, Clarke & Wilson 2008). The initiative involves developing a narrative of ways of coping (Clarke 2009). As well as introducing a simple psychological formulation based on ‘felt sense’ (Clarke 2008b) and delivered under supervision, the programme is designed to involve all members of the multidisciplinary team, with training offered to all, including senior staff. The intended vision is for service users to be given a consistent message and supported through the challenge of managing overwhelming experiences; as yet it is only partially realized. The current evaluation, combining quantitative and qualitative elements, will demonstrate how far it has been achieved.

As Chair of the Psychosis and Complex Mental Health Faculty (PCMH) of the British Psychological Society’s Division of Clinical Psychology, I am working to build alliances towards a more holistic vision of mental health problems. We are making common cause with a variety of stakeholders: service users, carers, psychiatrists (see Russell Razzaque, (2014), whose new book is along similar lines) and other health professionals. Our vision is to find a way of conveying a more hopeful message about mental health difficulties, in which the potential for a transformative journey can be embraced and supported. Here are some suggestions for how this may be assisted in routine mental health practice.

• Respect for experience. The experience of the mystic is respected in all cultures with the exception of reductionist scientism. Both the person with psychosis and the mystic are stepping ‘beyond the self’ and both deserve to be treated with respect. The propositional way of knowing is needed to engage with the everyday world of consensual reality but the implicational is equally a valid way of knowing. Without it we would be unable to navigate our relationships or to appreciate the arts.

• We must retain an open mind about the possibility of connection and influence beyond the self for those in a state of openness – whether it be a state of possession  or divine influence – while keeping in mind the tricksterish, ‘both/and’ logic that governs this area.

• ‘The feeling is real even when the story is highly suspect’. This and the concepts of ‘shared’ and ‘unshared’ reality are ways of talking with, and relating to, people in a psychotic state that holds the balance between the twin dangers of collusion and invalidation, and which facilitates a therapeutic alliance.

• Attend to the motivational dimension. What will best persuade this individual to join the rest of us in the shared world? Motivational Interviewing (Miller & Rollinick 1991) stresses the importance of maintaining and enhancing self-esteem and self -efficacy as an essential precursor to enhancing motivation. It means taking into account the effect of a diagnosis of psychosis and all the implications that follow on a person’s self -image. Mitigating this impact enhances the likelihood of engagement and treatment adherence.

• Finally, see this person as undertaking a (probably involuntary) journey into places that most of us will not encounter and from which, following the pattern of the Hero’s Journey into the underworld (Hartley 2010), they have the potential to emerge stronger, and bearing gifts for the rest of us.

Conclusion

This chapter is a challenge to those of us embedded in the prevailing system of mental healthcare. Katie, Satyin and Hilary all found that recognizing their psychosis as an actual or potential narrative of transformation enabled them to see themselves as pursuing an arduous but ultimately worthwhile path of growth. Katie is now doing important work with the local NHS Trust to incorporate an understanding of spiritual crisis into their spirituality policies and medical education and Satyin is embarking on a life of dedication through Buddhist ordination. Hilary sees herself as in the middle of her journey, coping with the setback to her confidence during her recent severe episode but still hopeful and working to change the paradigm. These accounts are backed up by summary of recent research supporting the value of transformative narratives.

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