Commentary on Mind Stimulation Therapy

Mind Stimulation Therapy (based on earlier published model: Multimodal Integrative Cognitive Stimulation Therapy-MICST)

Mind Stimulation Therapy (MST) , the earlier acronym was MICST (Multimodal Integrative Cognitive Stimulating Therapy) was pioneered in the course of my clinical practice over a 40-year period working with varied client populations across ages in varied settings: Outpatient therapy with “behaviorally challenged” children and adolescents; general outpatient adult clients; developmentally disabled adults; persons with schizophrenia in inpatient and Community Support Programs of CMHCS; dual diagnosed substance abuse clients; physically and psychiatrically compromised adults in nursing home settings. The MST model was further refined and developed through my years of collaboration with a former student of mine, Dr. Charles Boisvert, Professor of Counseling, and Education Leadership at Rhode Island College, and through our many collaborative publications with him, (see our publications in the bottom of Psychology and mental health resource links by Mohidudin ahmed

Below is my write-up explaining the MST model as well as a commentary by a Yoga therapist working in a community mental health center (with whom we have had no contact or association) that captures the essence of the model very well.

Mind Stimulation Therapy (MST) promotes awareness of the present moment of existence to maximize concentration to the immediate present reality of living experiences, physical and social surrounding, and one’s inner body cues through a practice of what we describe as Body Movement Relaxation (BMR) exercise. This exercise promotes the notion that seeing and experiencing one’s movement of body, one becomes acutely aware of one’s living existence, and a sense of affirmation of being alive, and one then can try to reflect on one’s personal connection to “others.” This simple series of exercises can be used to highlight the need for goal setting, identifying steps to goal, and the experience of goal attainment, which cuts across one’s daily life domains, including understanding of “Individual Treatment Plans” that many clients have in various program settings.

MST highlights that information processing is basic to all living beings. Having a sense of awareness of how we process “information’ in ways that are “adaptive,” can promote therapeutic dialogue to increase one’s adaptive thinking, feeling, and behaving, minimizing social and personal distress, and help best deal with one’s current life circumstances, and coping with whatever psychiatric difficulties that one may have. This processing of information is collaboratively discussed in the context of “here and now approach” of present “Reality of Living Experience.” It is grounded on the belief that all have some degree of capacity for adaptation to our life circumstances optimizing our functioning.

Psychotherapy interaction is often characterized by focusing on “so called clinical symptoms” or negative behavior traits client present that need “fixing” or “remediation.” This approach for many with long-term history of psychological problems and prior of history of many years of involvement in psychiatric treatment, and their own years of struggles in coping with these behavioral issues, may generate a covert negative relationship framework between the therapist and the client. Instead, MST model focuses on what the clients can do, and tries to stimulate activities and discussions that may involve general knowledge, science, mental health issues, religion or philosophy, or any other topic that client’s spontaneous utterances indicate interests and in which the client seems to have some knowledge base. This is supplanted with the use of paper and pencil cognitive stimulating exercises to access and stimulate client’s intact “cognitive skills” and “interests” to promote “reality based thinking,” and thereby strengthening clients’ ability to engage in “positive redirection activities” in presence of whatever clinical symptoms client may be presenting as per the clinical record. The goal is to approach management and reduction of “clinical symptoms” through the use of positive redirection (analogous to counter-conditioning)- a practice that we all normally do in our own coping with emergence of ego-dystonic thoughts and feelings in our daily life.

MST promotes reflection on existential perspectives (existential uncertainty, existential anxiety, and existential mystery) to help us see the time flow of our life as series of momentary living experiences, and to give us a sense of connection to living and non-living things around us, and help us see the World around as expression of an underlying universal “spiritual’ force, without necessarily contradicting one’s religious faith or science based knowledge. (We are all created from one God or are manifestations of one Whole- a Point of Singularity from the Big Bang: symbolically they represent the same concept). Past is important, if we choose to bring in to impact the present in the context of positive mental health and well being, or in the investigation of research on causative factors or to promote social action change. This will be a judgment call in clinical service setting and his orientation of therapy model that one chooses to practice.

Mind Stimulation Therapy believes that independent of any level of “disability” or psychological problems that one may present, everyone has functions and capacities that may be dormant but not readily evident to others, but with active exploration these capacities can be enhanced to contribute to one’s sense of well being. In the process, through involvement in these positively valued activities, they can help displace or “limit” the effects of “negative traits” or “atypical traits that cause personal or social distress.” The feeling of empowerment that may arise from this process of engaging in mind stimulation and positive redirection activities can spiral itself into promoting “recovery” or “enhancing functioning” in one’s own life.

Mind Stimulation Therapy does not actively review personal historical events to promote “insight and understanding” in people with long-term psychological problems or “limitations.” Exploration of “painful past” or “unusual behavior experiences” one’s life (e.g., reflection of our unique personal autistic and ego-dystonic thinking process, or habits of hallucination or delusions) may promote strengthening of these behaviors by reinforcing repeated visitations through a simple Law of Exercise, may impede practice of positive redirection, necessary for adaptive living, which we all practice in our daily lives.
In many persons with long-standing psychological problems, people do show or able to express “insights” in therapeutic dialogues, but it is the difficulty in translating these insights into behavior poses a stumbling block to recovery or toward movement to one’s own well being. (This may not be case for many with a high degree of intelligence and education and/ or motivation for self-reflection, and with transient experience of “psychosis” who may profit very well from such a psychodyanamic therapy approach.)

MST actively uses a multi-modal approach in therapeutic interaction, use of blackboard, computer screen, to maximize communication. It takes the position that auditory based conversational model of communication may not always be appropriate mode for these groups of clients who exhibit difficulties in working memory, control of repeated “intrusion of other thoughts” in the conversation flow, and in the practice of “redirection strategies,” that we all use to make our social or teaching communications effective. Therapy process need not rely solely on auditory based conversational modality: visual presentation of spoken words via computer screen, as we have had several publications using computer facilitated therapy, could be helpful. MST model assumes for these clients with long-standing psychological problems of developmental and or experiential origin may not have the capacity to internalized dialogue themes in therapy interactions and translate them into behavior change outside the therapy sessions. As such printed hand outs from sessions, follow-up practice in mind stimulating exercises, and active collaboration with client’s therapeutic milieu to ensure building prompts and support in the practice of positive redirection may be necessary to ensure maximal benefit from therapeutic encounters.

MST does not use a sequential training model, realizing many of these clients may exhibit variable emotional status or functioning on a day to day basis, so different element of the MST model may be highlighted or repeated in different sessions. Different elements of the MST model can be use or incorporated in practice of any therapeutic modality that clinician prefers to use, as MST model can be viewed as adjunct to any current practice of therapy.

The following review was written by yoga therapist who articulated very well the elements of mind stimulation therapy and its application to clinical population of Community Support Program where she has been working currently.

Mind Stimulation Therapy for Persons with Schizophrenia : Comment on Amazon website:Posted on April 25, 2014by OMpowermentYoga

“Before getting into the meat of this post, I feel like I need to touch base briefly on Schizophrenia. Schizophrenia is a mental illness that I think most people are familiar with, but know little about. Our stereotypes of people with Schizophrenia are largely shaped by the interactions we have with people affected by the illness. In the general public this may be limited to encounters we have with people in public forums – parks, malls, on buses or trains – and often are marked by their brevity. I remember the first time I ever encountered someone with Schizophrenia. I was taking the commuter rail back from an evening in Boston and a disheveled looking man entered the car I was on. He was exuberant, slightly raucous, and yelling at one of his pointer fingers because he thought it was talking to him. As he engaged in this conversation it was apparent that, at least in his mind, the conversation was a two-way one (although on my end that pointer finger never did reply!) In retrospect, there’s no way of knowing this man actually did have Schizophrenia. Any number of things can account for hallucinations – medical issues, drug use, etc – but as a younger person with limited knowledge of this mental illness my brain immediately associated talking to oneself with Schizophrenia.

Despite this very limited interaction in my earlier life, I feel fortunate that I have encountered people who experience mental illness in real and tangible settings, though growing up they were few. While many of us may know people who struggle with depression, anxiety, or substance abuse, Schizophrenia affects only 1% of the population. This means that most people will never knowingly encounter a person with Schizophrenia. Thus, many people’s understanding of this illness is based on fictional representations they see in movies or tv, characters they may read about in books, or the horror stories they occasionally hear via the news or internet. In these instances, their mental illness often becomes the headline and inevitably Schizophrenia is paired in people’s minds with violence. If you don’t believe this, do a Google image search for Schizophrenia and see what comes up. This is the first image I got:
This is the first image I got when Googling “Schizophrenia”
I bring this up now because since starting work in a community mental health agency I have encountered people with Schizophrenia regularly. Currently I work with a number in personal therapy. And guess what? They’re actually very interesting, resilient people who happen to struggle with mental illness on a regular basis. As such, I have begun researching treatment approaches to use with these clients that don’t forcefully challenge their beliefs, reduce the likelihood they will engage in therapy, or cause greater stress than what they are already experiencing. For a long time treatment for Schizophrenia has been primarily focused on medicating the client and changing their beliefs. For example, trying to convince your client that his or her next-door neighbor ISN’T controlling his mind. However, as a longtime yoga practitioner I’ve always felt a little bit unnerved with approach, which I believe lacked some of the core components of my daily yoga practice: acceptance & non-judgment. Thankfully while completing my master’s degree I was introduced to a way of working with clients diagnosed with Schizophrenia steeped in a positive psychology framework. And that way now has a name: Multimodal Integrative Cognitive Stimulation Therapy (MICST).
MICST is an approach steeped in learning theory and positive psychology that emphasizes the role that our environment and interactions have in shaping who we are. With Schizophrenia, the creators of MICST (Ahmed & Boisvert, 2013) argue that portions of symptomology may actually be reinforced unintentionally by a person’s environment (friends, family, therapists, community interactions). So what does this mean? Basically, that Schizophrenia is an illness that can manifest itself in a number of symptoms. But by constantly pointing these symptoms out to clients and arguing against them (i.e. “These things aren’t real.” “You’re just sick.” “No your neighbor isn’t spying on you!) we may actually be reinforcing these symptoms and further entrenching them within our clients. Thus, MICST encourages practitioners to to emphasize reality-based behaviors and beliefs, and to focus on on what client’s do well rather than reinforcing their deficits.
Instead, the authors emphasize using a positive psychology framework “to enhance self-esteem and well-being,” by focusing on client strengths rather than their weaknesses and utilizing cognitive stimulation “to access areas of intact cognitive and memory functioning.” The authors who created MICST suggest three basic ways of doing this:
1. Body movement-Mindfulness-Relaxation (BMR) exercises
2. Group Discussions
3. Paper & Pencil exercises
As I read through this treatment approach, I can’t help but notice the similarities I see between the recommendations set forth in the MICST manual and components I find in a really great yoga class:
 Acceptance: Encouraging your students to accept themselves where they are at rather than emphasizing failures or unmet wants & desires
 Non-judgment: Role modeling your own personal acceptance as a teacher for your students and encouraging your students to engage in personal growth without harsh criticisms against themselves or others
 Asana: Engaging in physical exercise to provide a point of focus or “moving meditation”
 Mindfulness: Reminding your students over and over again to be in the present moment (often I hear this with a phrase like “be on your mat,” or “Notice what’s going on with you on your mat today.)
 Relaxation: Taking Savasana at the end of class to integrate everything that you experienced during class
 Cognitive Stimulation: I would argue that through the joint practice of mindfulness and movement, with the added component of education on yoga principles or mental health topics at the beginning of class that yoga is an excellent cognitive stimulation exercise
 Group Discussion: Who hasn’t gone to a yoga class and either engaged in conversation with their yoga buddy or with classmates? But I’d argue a really great class includes some discussion about the class theme, or a check-in with students, at the beginning of class (and is a two-way conversation)
Looking at that list and reflecting on the philosophy of MICST, it’s no question that components of yoga can be beneficial for patients with Schizophrenia (or that practicing yoga can help therapists acquire the skills necessary to serve their clients in the most effective way possible). Next week I’d like to follow-up on these similarities further, focusing specifically on the BMR component of MICST and how yoga can help to play this role in clients affected by Schizophrenia.”

Further Comment on Mind Stimulation Therapy:
” I do believe that there are different pathways to achieve positive results in therapy, as psychological profiles are unique and different from person to person, specifically for those considered to be having severe and persistent mental illness, which by definition means that this client group has not responded to any current standard psychiatric treatment protocol by history in a very positive manner. So there is need for use of innovative and creative approaches in working with this challenging population.

Success of therapy may also depend on what should be the target of intervention. It is a complex process, as you rightly pointed out, and a very evolving one too. What makes sense now, may be different later with more knowledge and understanding, and advancement of communication technology.

Mind Stimulation Therapy is viewed as adjunct to any ongoing clinical interventions that the client may be receiving from other service providers, , and one can choose to incorporate whatever elements of the model presented in the particular brand of therapy that one choose to practice or promote incorporation of the elements in the milieu intervention of the client.

My experience in working with people with schizophrenia (I am using this label until a newer and less stigmatizing name is adopted, but it does serve a denotative function for communication here. and you may have read a discussion thread sometimes ago whereby we presented a model of Atypical Thinking Psychosis as an alternative name for schizophrenia in a response letter to Bill George and A Klijn in the Lancet Psychiatry a year ago) has been primarily in state psychiatric and Community Support Programs of CMHC facilities. Almost all these patients/clients demonstrated varying degree of difficulties in 1) working memory (holding information on line (in head) to solve a problem), 2) episodic (personal) memory, and 3) semantic (knowledge based factual) memory. While for 1 and 3, one can provide objective feedback, but for #3, personal memory (analogous to belief as to what happened in the past, it is difficult to do so. As it can be compounded by objective experience of recall, subjective interpretation of the experience that is recalled (often in bits and pieces), and added with subjective feelings and personal imaginations or interpretations. While there is a value to explore these past memories objectively and symbolically for some, but not sure how productive will it be for the kind of population that I am referring who may have gone through this “recall phases” many times in their own personal life or induced by other care givers in the past. It may be very productive for other client populations, as many will testify. I don’t doubt it.

When I was working at a state inpatient psychiatric facility in the 80’s, many of the patients were described as not being suitable for any kind of psychotherapy, individual or group. Psychologists were the only designated provider of psychotherapy for the patients, and only a few who were highly verbal and reasonably stable were seen in individual psychotherapy. There was no provision for group therapy then. And there was of course the resource limitation and availability issue too.

I started the first group in that facility in a psycho-geriatric unit, the most disabled group in the hospital, enlisting a social worker as a co-leader, after formulating a group protocol similar to what would later evolve as Mind Stimulation Therapy with varied activities.

Initially we labeled it as cognitive skills training psychotherapy group. The model was partially based on several dimensions of my previous experiences: 1) Providing conjoint therapy/consultation (with casemanager present) with CSP clients in a CMHC, all diagnosed to have schizophrenia, incorporating visual modality rather than just verbal conversation, to make our session conversation more effective. For example, I would type and show the client on the computer screen the major themes discussed, and give print outs to the client and the casemanager. This technique would later be labeled as computer facilitated therapy, and we have published several articles in peer reviewed journals, see publications in my website: 2) Conducting ADHD children group in a CMHC, using paper and pencil cognitive stimulating and self-reflection exercises, a first of its kind to conduct a group at that facility then (early 80’s). 3) Managing a DMH research funded day and residential treatment programs for “mentally retarded and emotionally disturbed adults” living in the community on the grounds of a state inpatient facility (for the developmentally disabled populations).

So the MST model does incorporate all these different experiences of mine of working with challenging mental health clients in various settings. I have used elements of the MST model with dual diagnosed substance abuse clients in two residential programs, and presented our work at 23rd and 26th Cape Cod Symposium on Addictive Disorders, and last clinical was in two nursing homes where I used the model with geriatric clients. I am currently involved in providing consultation to Applied Behavior Analysis oriented Treatment Plans for the developmentally disabled adults (many with a concurrent dx of schizophrenia or other psychotic disorders) suggesting ways to incorporate elements of the MST model into milieu program and in the behavior training approaches. So Mind Stimulation Therapy has varied applications to diverse clinical populations.

But I do agree that one needs to be open to using different approaches in working with challenging mental health populations, as long as one is clear what outcome one is striving to achieve collectively with a client and with client’s significant others who may be involved in clients’ care or well being. There should be some kind of objective criteria to assess progress, however limited, they may be, rather than going by one’s commitment to a therapy model, without assessing whether it fits the client’s needs or functioning or not. I have often heard that “so and so patient is not ready or not been able to use therapy when offered” somehow implying the patient does not match a therapy model that the clinician has been trained in , and not exploring modification of a therapy approach to fit the particular patient needs.

Of course there are time constraints and resource commitment issues that professional and agencies serving this type of challenging mental health clients face, so there is less opportunity to engage in innovative practice or going beyond one’s expected defined roles.

But keeping an open mind does help to make some impact in a positive direction. After all, Reality is multifaceted, and there is validity to different perspectives, and there are many ways to reach desirable goals!”

Positivist Thinking and Probabilistic Knowledge

“I read both of your comments and learned a lot the way you presented the contrasting views of the Positivist approach with emphasis on verifiable quantitative data analysis and the phenomenological based approach using qualitative data. I agree with the problem of using efficacy based or experimentally designed based practice to any member of a specific group of individuals on whom the research may have been conducted, without taking into consideration of the unique individuals functioning and their own phenomenological experiences that guide their behaviors, as I understand Paris was also mentioning.

Objective study is difficult, as any method used changes the behaviors of the persons, analogous to Heisenberg’s Principle of Uncertainty when applied to predicting behavior of individual electrons, as they are changed by the instrument of observation used. In terms of clinical practice, it does boil down to use of eclectic, intuitive, and experiential knowledge of the clinician to collaboratively work with whoever client one is working with in dealing with one’s psychological problems in question. Evidence based practice models, or any theoretical models that one has been trained in, are just some useful guidelines, which need to be creatively adapted in conjunction with other knowledge of service systems and social and therapeutic milieu that the client is involved in to make the therapeutic dialogue and collaboration effective.

The social-existential reality is much larger than the typical weekly experiential interaction that a therapist has with a client. In the same vein, psychological problems and human behaviors are too complex to respond effectively to any biological based intervention alone.”

Probabilistic status of all human knowledge

“Knowledge is probabilistic, there is no such thing as all or none approach that fits all, and we need to guard against substituting one dogmatic position over the other, and be open to the idea that some cases may not fit to a given conceptual model or explanations, and some do.

Emerging empirical evidence and change of social culture and acceptability will determine a lot what is considered to be “sane” or “not sane” at a give time of history and culture. Acceptability of any given model of practice will depend to the extent it makes logical sense to people involved, and its ability to reduce “distress” (e.g., subjectively and objectively) of a human condition. One needs to acknowledge that there are different stakeholders (discipline involvements) in this effort coming from different perspectives. Each discipline perspective will have to make a case on its own merit to the public at large without necessarily contradicting or comparing with other perspectives. And there is the whole issue of application of any well thought out theoretical model, however logically it is constructed, to real life situations. It is a challenge to any practitioner from any discipline training.”

On the need for emphasizing spiritual and phenomenological human experiences in therapy and counseling

“As I understand many people ( who I personally interact with, and others at large with whom I have had experience in dealing with in my life time, or have come to know of others through my reading of books or through media) practice some form of faith of religious or spiritual nature that are beyond the parameter of experimental investigations.

Such practice of faith helps them to deal with the Reality of Uncertainty and the Unknown. The faith based areas of spheres may operate independently of other areas of their everyday life or professional science or knowledge based practice, and do not appear to be amenable to any rational discourse. People appear to be quite happy or contented in having these compartmentalized domains of functioning, which may follow different sets of rules or logic, avoiding any experience of cognitive dissonance or disparities between various forms of knowledge, say same science based concepts, such as theory of evolution or evidence from astronomy with their personal religious beliefs and practices.

Even within the experience based paradigms of knowledge, there are different ways of conceptualizing the Experiential Reality.. Emphasis on a particular research or advocacy in no way negates the reality of other types of research and advocacy for a particular point of view as the case may be. Human behaviors and functioning can be viewed from different perspectives, and from different dimensions. It is difficult to say which one is more valid than others. So it often better to avoid comparisons, rather make a case on its own merit. Of course, there are situations where comparative studies and experimentation are necessary to evaluate effectiveness of one over the other, as is routinely done in research studies involving criteria that are operationally and objectively defined, but they have limitations to areas of complex human behaviors. Making a case of acceptability and valuation of a particular model or idea at a particular time of social development and readiness for acceptance will always be a dynamic and fluid process, reflecting evolving stages of social and cultural development and current values. What appears to be “true” and makes sense to others” (with like minded people) with supportive evidence presented, may not be acceptable to other groups of people with their different cultural or sub-cultural identities, and with their varied disciplines of human service provider identifications.

Nevertheless, I do agree that the spiritual dimension of human experience is not often integrated in scientific research in human behavior or not being acknowledged as of being important. Perhaps, may be because people become extremely sensitive, whether scientists or non-scientists, or learned scholars and practitioners of any disciplines or public in general, to any questioning of their personal faiths or beliefs. Rational discourse is fraught with all kinds of implications, and has the potential for bringing about “turmoil” as past and current human history reflects. Scientific endeavors somehow need to perform a balancing act, respecting tolerance and acceptance of diverse spiritual and religious faiths, and acknowledging the fact that societies are unequal in t heir development for tolerance and acceptance of diversity of human opinions and faith expressions.

Besides, I believe, not everyone is comfortable in living with the knowledge of Mystery and Uncertainty of human life experience. That is where the appeal of some of form religious and spiritual faiths for billions of people all over the world comes in. There are some who are okay with it in coming to accept it as the Natural Law, and some may find it as impetus to their own creativity in different forms. And some may struggle with it on a daily basis. And some may find themselves caught up in the riddle of solving the Uncertainty and Mystery of Life and the Universe using an non-consensual validation process, unlike the astronomer scientists, through their own personal phenomenological journeys. In the process they may enter the Black Hole simile of the Unknown and Unknowable world. For many, with intelligence, education, and support, they are able to climb out of it, come up with some insights and understanding that may be appealing to them and to other, and they are able to practice “redirection’ away from these personal moments of “existential preoccupations” or “crises,” so they can enter and exit the process. Bu some may have difficulties in doing so, and may find themselves caught up in the process, causing neglect to one’s personal and social well being, and may exhibit considerable impairments in functioning, associated with personal and social distress, which may be associated with some form of mental illness or people with long standing psychological problems reflecting an unique set of developmental history, and an unique set of adaptations to their “existential crises.”

There is always a room for new ways of looking at things in different ways: trying to improve our own understanding of human life experience, how to improve the quality of life of people that we are connected with or serve in our professional capacities, , and how best to advocate funding and research support or undertaking investigations within various disciplines of our knowledge. Any endeavor in this direction is laudable.”

In relation to this, I am quoting another commentary:

“…You do capture the tormented experience of the living soul who is willing to accept “anything” to get relief or escape, which all of us may feel at some moments of our life, but some may find themselves experiencing this more intensely and persistently than others.

I have taken the position that we may not have the knowledge yet, other than speculations, and have many contradictory views as to “Why” these experiences happen to people. Some with intelligence and education, along with other psycho-social support, are able to navigate successfully through this “why exploration process,” but many find themselves caught up with preoccupation with this persistent “distressing mood” for years. and cannot seem to get out of it with or without all kinds of “interventions.” For them, “What” may be a more productive focus in terms of highlighting with some degree of objectivity what can be done to reduce the “tormenting experience” and facilitate positive redirection,” to various “activities and pursuits,” which is, in a way, a part of our daily routine that we all try to engage in….I do believe that there is need for change in social milieu or what one may call therapeutic milieu. So any form of “therapy” or “counseling” or mediation intervention for that matter to be successful must be integrated into one’s social or therapeutic milieu. That is a daunting task not yet addressed fully or built into professional training and practice of a clinician or within the institutional culture of mental health that one operates within.”

How best to deal with “past trauma based experiences” in people with long-standing psychological problems

“While there is an increasing acceptance of relationship of “trauma’ based childhood experience and development of psychosis, but there is also a need to understand the positive role of individual and cultural resiliency to the experience of dealing with “childhood traumas” or with the “adverse negative life experiences” of one’s life and circumstances. Freud’s classification of “defenses”: repression, suppression, sublimation, and I would add to the list, positive redirection for participation in various “other activities” of daily life (this may be a form of sublimation also), are all necessary adaptive mechanisms that people have used and are using all over the world to deal with “traumas” or “negative life experiences in their personal lives.

Millions of children, especially in the under-developed and poor countries, do experiences unfortunately “traumas” of all kinds for a variety of social and economic factors. (This understanding is also partially based by my personal experience of living in that part of the world.) But not all experiencing such “negative life experiences” develop “psychosis” or schizophrenia, or persistent psychological problems later in life, while some may do so. Although many of them who do not may have other disadvantaged conditions associated with poverty or other social or economic disadvantaged factors affecting their lives.

In this country many famous and successful people have divulged their personal experiences of “childhood sexual abuse or trauma” but did not develop psychosis or schizophrenia. Granted that any form of negative childhood social experiences should be expunged from all societies, (and many of us believe that societies all over the world, hopefully, are evolving in the direction of improving the quality of life for all- although it is a long way to go, given the wide spread poverty, unequal distribution of wealth, economic and social development, and the continuing present of current world wide political and social conflicts and turmoil). But these “negative experiences” alone cannot be viewed as an universal template that can be used to explain psychosis or schizophrenia. There are many other factors that may be involved for different individuals who may develop schizophrenia or long-term psychological problems shaping their lives negatively. We need to be more open to research and understanding that our knowledge and science is not complete in this area yet. Parallel and integrative research into biological and psycho-social factors that may contribute to schizophrenia and psychosis are valid avenues to pursue, and if one may choose to focus on one, it does not mean negation of the other. It is how research and information is presented to consumers who ultimately will make the decision as to what works best for particular individuals. It is in tandem with consumer focused market oriented service industry of the present day world!

I believe that while historical analysis of psychological problems (“traumas”) may be helpful to some, but it may not be helpful to many with long-term history of psychosis or psychological problems, Focusing on What one is doing in the Present Moment of Existence, not on Why (as it may lead to all kinds of theories and explanations, and may delve into the realm of Known, Knowable, Unknown, and Unknowable events of one’s unique past). Such repeated explorations and visitation to these experiences may, in fact, unwittingly reinforce the experience of “memories of traumas” with possible “negative effects,” as repeated visitations ( by self ruminations or therapy process)to these experiences can also lead a “habit” of feeling depressed and agitated by a simple Law of Exercise, as may be case with some “clinically depressed individuals.” As I understand , we all practice our daily lives some form of active positive redirection (through involvement in varied activities of our daily life, including involvement in religious or spiritual practices) to ward off our own “negative thoughts and feelings” that often crop up anytime and anyplace in our lives.

I do acknowledge that in some situations, exploration into the past painful experiences may have positive benefits by raising for some ( as well as their therapeutic social milieu) awareness as to what can be done differently to deal with their present life circumstances so as to improve their quality of life. For the same reason, it may a be worthwhile pursuit when conducted in the context of a legal advocacy or social reform or research studies to understand and prevent “traumas.” It may also be productive in the context of helping some who have “intact cognitive functioning “and demonstrate a capacity to tolerate such explorations and developing insights to carry them forward in their personal life as well as providing them with meaningful desensitization experience to their past traumas, thus giving a “cathartic” like positive experience.

But for many, as we have proposed in our book (Mind Stimulation Therapy: Cognitive Intervention for Persons with Schizophrenia, page 142), “cauterizing the personal wounds” and stimulating the “surrounding intact areas” to promote positive mental health for “recovery” as opposed to “bleeding the wound” for the purpose of “healing” the “psychic wounds” might be a useful strategy, in conjunction any other current therapeutic modalities that the person may be receiving.

Again, it is a clinical judgment call on an individual basis, not a universal template to be used with all.”

“I am not questioning exploration of unique phenomenological experiences for potential validation of “abuse related experience” that need to be pursed in the context of personal psychological benefit, or from the perspectives of legal ramification, or personal or social advocacy. I was questioning the “exploration issue “in people with long term history of presenting psychological problems, who may have repeated exposures to exploration of their unique past, and may have developed unique behavior habits to deal with their experiences, and this repeated “explorations” may take away the focus on the Present Reality of how to make the most sense out of one’s present life circumstances, After all that is the Reality that we all have to deal with. Whatever the past we have is an integral part of our lives, they cannot be re-written. We have a choice to leave them behind and move on. It is difficult to pass a value judgment which is more adaptive. There is a danger in imposing one own commitment to a “model” or conceptual understanding of a situation to different individuals, the dilemma that we talked before. Again, it an individual case by case situation, and one needs to use the best judgment one has by being “open ” to different possibilities and approaches.

Finally, In any therapeutic dialogue of two persons, there is an overlapping area of the Venn Diagram where communication is possible and happening, and the non-overlapping areas reflecting each individual’s unique phenomenological experience of Reality that may not be communicable to each other. This I refer to be in the domain of Unknown and Unknowable. Any therapeutic dialogue could be both a process and an end, When I used the “cauterization” simile to healing of the psychic wound, I was emphasizes the effort to renewal of self and developing a newer “positive” identity by focusing on the Present ( the What experience- What one is doing now) than on the Past (Why exploration).”

Capacity for discovering insights may be present in all of us in some ways independent of level of education and the importance of use of positive redirection

“In a way, we are all thinking alike with slight difference in expressions. I watched today a Russian documentary of a trapper’s life in Taiga over a year period. What impressed me most that this person, who appears to have limited education, but based on his practical life experiences of training dogs and living off the land with harsh surrounding, and years of self reflection, was expressing philosophy of life and behavioral psychology in a way that resonates with the writings of eminent thinkers and psychologists. I believe that millions of people all over the world, many with limited or no education, including people with schizophrenia may have some degree of insights and knowledge of life, that people become famous for writing them. Often this may not be readily apparent to others. You may have read Herman Hess’s Sidhartha, where Gautma got the most enlightenment by being with an illiterate boatman whose job was ferrying people, and in his past time watching the flowing river from which he claimed to derive much of his wisdom through self reflection. All these people do not have the opportunity to express their innate wisdom and thoughts that are buried within them or they lack a vehicle or medium for expression or in our modern business jargon, marketing their ideas.

From a mental health perspective, that is another form of strategy to use to all the others that are in vogue: how to have people with schizophrenia express their hidden “positive” knowledge and wisdom and use them to their benefits to reduce their personal and associated social distress, again focusing on what they have, not so much what they have lost or do not have, as it may take into a whole new direction in the therapy process that may or may not be helpful for reasons I cited before.

My sense is that independent of whatever “unfortunate life experiences” we face (including “birthing trauma” and “psycho-social induced traumas,” and the accident of birth -in terms of place and situation where we are born and grow up as human beings), we all live in the Present Moment of Reality and try to figure out how best to deal with that Reality of Existence, where Past and Future are not there in our immediate consciousness, and Uncertainty of the Future dominates. Our Past and Future are experienced in the Present, in the context of memories and projections. They are often influenced by our “real life experiences” and embellished with our imaginations, subjective judgments, interpretations or selective extrapolations of our our past memories and future anticipatory goals All of these are often difficult to sort out. “

“Yes, many of us think alike in many ways coming from different backgrounds of all kinds.

We are all connected souls, more to some than to others, by choice and circumstances of birth and living experiences.

Discovering the “same ideas’ could be a reflection of what Plato described in the Theory of forms, where the Ideas are embedded in us, and we discover them as knowledge, or what Jung’s theory of Archetypes as the common basis of mythological stories across cultures, or what Kantian view that all of us experience Reality from a priori given Categories of Mind.

I am sure a lot people, all over the World, independent of their knowledge and surroundings have deep insights and understanding, but because of lack of tool of expression or a vehicle to promote their thoughts, they are not known to others. New knowledge and understanding, also, is sometimes putting the old wine in a new bottle.

In my clinical work with people with long-standing psychological problems,(people with substance abuse, schizophrenia or nursing home patients),I was amazed to find the degree of insights many of them demonstrate, given a framework of dialogue process. I feel the challenge in working with many of these clients is not “helping them with their insights,” which they may already have, but more in terms of how to help translate “the insights” into changing their personal life and the therapeutic milieu in ways that “change” becomes a reality for better for them and as well as for the significant others in their lives.

That is easier said than done.”

Importance of focusing on emotional state that trigger long standing psychological problems for target of clinical intervention

“Thanks for posting this very important article Luc Ciompi (Key Role in Emotions in the Schizophrenia Puzzle in Schizophrenia Bulletin, vol. 41, no. 3, pp 118-122, 2015) A lot of points Luc Ciompi makes resonates with my views also, as I feel, emotional dysregulation (intense agitation-stress experience) may be the origin of atypical thinking and behavior and may well underlie the development of psychosis and schizophrenia (a la Freud’s psychotic defense in the presence of overwhelming existential anxiety).

For many, especially with a history of persistent psychosis with compromised functioning of long-standing nature, medication does have some ameliorating effect on stress agitation level, making the persons more amenable to therapeutic prompts by restoring some degree of homeostasis balance in some ways so as to make the persons think more adaptively in terms of “here and now” existence, and correspondingly increasing their capacity to respond to “therapeutic prompts” and participate more readily in positive redirection strategies, enhancing overall functioning. But “atypical behavioral symptoms” characterized by hallucinations or delusions may have become “behavioral habits” over time and not responsive to medication treatment for many of these people. I have made this case in several of my previous postings.

(I am not proposing that people who for some reasons others develop habits of engaging in hallucinations and delusions as part of transitory or life -long experiences are necessarily have schizophrenia or psychosis, which depends on significant impairment in adaptive functioning and sense of caring for oneself.)

But unfortunately medication practice for persons with schizophrenia is targeted to eliminate or reduce the so-called “behavior habits,” and often results in over-medication, or unnecessary medication with resulting side effect issues in the pursuit of something that it cannot achieve .(Calming effect of any medication practice may for some reduce the discomforting effect of hallucinations and delusions, making for some more tolerable with these symptoms, but there is no evidence that medication eliminates them.) Elimination or reduction of “behavioral habits” may need to be addressed within the framework of psycho social intervention and in the context of social and cultural practice or determination to the extent they cause personal distress or perceived social distress associated with the history, not potential for “at risk behaviors.”.

Efforts to reduce agitation arousal stress experience must include research in more targeted medication practice such as reducing the presumably involved chemical transmitter, dopamine on the mesolimbic system ( supposedly responsible for emotional regulation), but not reducing the frontal lobe functioning (supposedly involved involved in planning and thinking).This has not happened yet, causing positive and negative effects of psychotropic medication. As I understand, anti-psychotic medication has a generalized effect on reducing dopamine everywhere in the brain. May be future medication research will be more promising. There is also corresponding need for exploration of different ways of providing therapy and therapeutic and milieu supports to maximize individuals own capacity to think, feel, and behave in ways that reduce personal as well as social distress.

(By the way, I am not proposing that everyone will need or benefit from a biological based medication approach, but some do and some may not need at all, or some may need occasionally, and the therapeutic benefits that the medication brings about can as well be achieved potentially by psycho-social intervention and presence of personal traits, and It will be a judgment call on a case by case basis.)

From the psycho-social intervention perspective, one may also need to view how the traditional “talk therapy” or variant of it focusing on “deficit focused” approach and revisiting one’s personal history and past “negative life experiences” is helpful or not for people with long-term persistent psychosis and schizophrenia. There is also a corresponding need for acknowledging the “intact areas” of one’s functioning and resiliency, how best to promote stimulation of these areas to enhance sense of well being and functioning, no matter how “disabled” the persons appear to be. Focusing on their “long standing habits described as symptoms, (hallucinations or delusions as the case may be, or other forms “maladaptive behavior symptoms), and focusing on their presumed historical origins, whatever they may be, in conjunction with a corresponding focus on the “expressed deficits” the persons currently display- reflecting the “judgment” of the “care givers or the ” helping profession,” may not be the most productive way to practice for this clinical population. As these strategies may generate a “negative relationship between a therapist and the client, as well as covert or overt “agitation and stress arousal symptoms,” instead of “reducing it”, and also may reinforce the continued identification with the “illness persona” that the persons have come to believe in, which may unwittingly counter the need for increased identification with positive self-image. There is a positive benefit of emphasizing being in the present “here and now existence,” learning relaxation-mindfulness and other coping strategies, as well as learning to engage in a variety of mind stimulation strategies, and developing a sense of connection to others through existential discussion perspectives, and in the use of positive redirection activities- thus helping them make the best of one’s present life circumstances.

Beside people with long-standing history of schizophrenia may have compromised ability to respond to auditory based conversational mode optimally and may have impaired capacity to internalize verbally mediated information processed in therapy, and in their ability to translate changes in their personal life outside the therapy session without therapeutic prompts built in the setting. I have commented in this before here and in our publications.

(This point I am making may not be case with highly intelligent and educated people who for some reasons develop transient psychotic episodes and have the intact capacity for internalization and self-reflection, and retain the ability to change their thinking, and life styles with or without support or having profited from therapeutic support in the past to recover their functioning.)

Working in state inpatient facilities, community mental health centers, and nursing homes, I found that many people diagnosed or treated with schizophrenia have different developmental histories: learning disability, substance abuse, mental retardation, as well as childhood trauma and or negative life experiences. Any strategies that involve greater emotional stability by medication and or psychotherapy process will enhance each person’s capacity to maximize his or her thinking as to how best to manage the present reality of living experience in collaboration with support of “significant-others involvement” and the mental health community at large.

It is also worthwhile to read another article published in the same issue in Schizophrenia Bulletin, First Person Account, “A Carer’s Perspective: The View From Australia” by Paul Kauffman.

It describes the kind of people with schizophrenia that I have mostly encountered in my clinical work over a 40 some years, which does not include, I must confess, outpatient therapy with mostly intact cognitive functioning people associated with a high level of education, and suffering from what appears to be “transient psychotic experiences.” and have the demonstrated capacity to profit from traditional psychotherapy modalities. So my comments are limited to the group that I have worked with. Nevertheless, my sense is that this group may constitute the largest percentage worldwide, who are identified as people with schizophrenia. This article describes what the advocacy role, (family) can achieve to enhance quality of life and functioning, to significantly impact “improvements,” within however some “persistent disability framework.,” which unfortunately many people with longstanding history of psychosis and schizophrenia exhibit. Considering that many persons with schizophrenia may not have this kind of family support or advocacy, my sense is that the quality of life for many of them may be much more compromised than what is described for this person.

So much more work needs to be done in practice innovations and research in this area of mental health service for this population. It is in a way this is an exciting field for patient, patient advocates, and mental health professionals that there are all kinds of possibilities to move forward in different directions to improve the quality of life and care for people with psychosis and schizophrenia of varied manifestations.

But one needs to be open, not judgmental, and not be dogmatic in trying to impose one’s specific professional training or identification with a model that one has been exposed to in training. Given the individual and cultural variability and circumstances in people with psychosis and schizophrenia, one has to be “creative and innovative” in clinical practice, whether from medication practice or psychotherapy practice perspective.”

Thoughts on “Soul”

“Yes, millions of people believe in the existence of Soul from the perspective of a religious and spiritual dimension. It is considered to be a greater part of the Mind, and continues to exist in some form beyond the entropy of the body, of which mind is a function. That is an area of faith and existential and religious belief of billions of human beings and probably is not a subject to a rational discourse and does not necessarily invalidate its “existence.” It is one of those Unknown and Unknowable domain of knowledge, for which one can have infinite ways of conceptualizing, and many choose to adhere to a collective religious faith. Living in an Unknown World of death that we all face, such beliefs do need respect and understanding,
The concept of extended mind also applies to the body, as our body is interacting constantly with the immediate and visible universe. Deepak Chopra made a similar case, I believe, in Ageless body and Timeless Mind. I believe that there is a lot to be known about mind-body relationship and its “extended functioning,” and there will be a constant interplay of speculation, belief, and ever growing knowledge around this. While changes in body with changes in mind and vice versa will be increasingly demonstrated through empirical evidence as more investigative technology is developed, and perhaps potentially also demonstration of evidence for “extended body” and “extended mind” through parapsychology research or non-contact therapeutic touch practice research or variation of it) but the duality of mind and body as wholly separate entities will rest a great deal on existential and spiritual faith that one holds.

I believe there is a limit to human knowledge: a lot of things we know and will know, and a lot our ideas will reflect our personal and faith valued beliefs, and a lot more we will never know and will remain a mystery to us. Sometimes it gets blurred what we know, what we don’t know, and what when we say we know but we really don’t know, and what we never will know. The last one is a great equalizer to all of us. One can identify with Einstein or with all the great geniuses that they also do not know what we do not know – the Uncertainty of Living Experience, putting us all on the same boat. I have used this kind of discussion, more in the recent past, in working with nursing home clients to uplift their spirit.”

On Further Thoughts on Mind-Body Relationship Issue

“You have my support and understanding of the views you presented and articulated so well. . Many of us agree with the position that mind and body are parts of the two sides of the same coin. The degree of biological and psycho-social intervention will vary depending on what appears to have the predominant influence on the expression of the “disorder “or “dysfunction” or “psychological malady, “and in many situations one may need both to a varying degree, and in some cases, one may need one to the exclusion of the other, supplemented with “natural support,” and therapeutic milieu, and client’s inner strength and resiliency to promote maximal recovery.

Intervention research and advocacy can proceed on a parallel process. Highlighting the advocacy and research for one dimension, does not necessarily deny the value or usefulness of the other. What is important is that over reliance on one, without functional behavior data or concrete individual based data evidence to support usefulness of a specific intervention, without consideration of both unnecessary dependency or “abuse” and “side effect” is problematic. The dialogue is often caught up with politics of mental health and “turf” issues, and need for advocacy for a particular dimension for research and funding support. That is quite understandable, as advocacy role may require that kind of one sided presentation of view.

Consumer knowledge and advocacy from groups of people like you can make all of us aware of a sense of Reality from the sufferers and recovery of clients perspectives. . Unfortunately not many patient-consumers are articulate and verbal as you and your group seems to be. Like many professional care givers, my perspective has been limited, even though I may share some “patient” characteristics, as human being all of us may do, but not really living through some of the “challenging experiences and undergoing all kind of “interventions” that you and others who identify as former “patients” or recovering patients have gone through. I applaud your feeling of being Okay to be identified with the label of “patient.”. But that is a personal choice!”