Are we mindful of psychosis?

We intend to offer the readership a general understanding of the neuropsychological processes involved in contemporary approaches such as Mindfulness-Based Cognitive Behaviour Therapy (MBCT) and MindfulnessBased Stress Reduction (MBSR) by using the subject–object paradigm. We conducted a literature review using Medline, with search terms ‘attention’, ‘mindfulness’, and ‘meditation’ in October 2011, which yielded 591 results. We focused on articles discussing the neuroscience of meditative states and, in particular, the effectiveness of meditation-based approaches in people suffering from psychosis. We came across an informative article by Allen et al. (2006) that provides an overview of mindfulness-based therapies and practical considerations when applied in clinical situations. Mindfulness has been described as “paying attention in a particular way: on purpose, in the present moment, and non-judgmentally” (Kabat-Zinn, 1994). When a person is mindful they have an expanded awareness of internal (originating from the self) and external (arising from the environment) events, and accept them as they are, without attempting automatically to alter associated thoughts and behaviours. Mindfulness-based therapies therefore differ from traditional cognitive-behavioural approaches in that there is no attempt to dispute dysfunctional cognitions, but to accept them non-judgmentally (Allen et al., 2006). When a person meditates, there are experiences of general well-being, enhanced attention and positive effect. Neuroimaging and electrophysiological testing correlate these findings with increased cortical activation, specifically in the anterior cingulate and prefrontal cortex. These functional cortical changes are evident even after short periods of meditative therapy (Rubia, 2009). Mindfulnessbased cognitive therapies are effective in improving attentional focus and quality of life in patients with clinical depression, anxiety, eating disorders and chronic pain syndromes (Allen et al., 2006). We observe that the clinical benefits in the above conditions are due to a common denominator; a metacognitive consciousness cultivated through meditative practice. Raffone and Srinivasan (2009) suggest that this metacognitive consciousness encompasses any form of awareness based on the subject–object cognitive duality. That is, when a person (the subject) attends to an internal or external ‘object’ (for example, a bodily sensation or a flower), there is a subjective phenomenal experience (cognition) of that object based on past experiences and ingrained patterns of thinking. A metacognition would go beyond the cognitive subject–object duality, as the ‘awareness of being aware’. Clinically, if the subject is the depressed person and the object is a self-critical thought then the phenomenal experience of such a thought would be a depressive cognition. Rather than challenging this cognition, a metacognitive awareness cultivated through mindfulness would allow a non-judgmental appraisal of the present moment without succumbing to repetitive detrimental patterns of cognitions that worsen the depressed state. In practice we see patients (the subject) who suffer psychotic phenomena like auditory hallucinations (the object), often find these symptoms to be greatly distressing. If they are trained to have a non-judgmental awareness of the phenomena, the automatic catastrophic emotional res ponses to derogatory hallucinations can then be modified. This has been substantiated in recent studies of mindfulness in patients with psychosis when used in controlled, clinical settings (Chadwick et al., 2009; Jacobsen et al., 2011). Whilst these preliminary studies have highlighted the effectiveness of mindfulness-based approaches in psychosis, there are some hypothesized challenges and risks. Pinto (2007) suggests that patients require a sufficient level of insight into their condition, and adequate trust of the therapist before such treatments could be considered. The greatest barrier, however, may be the skeptical attitudes of mental health professionals in regard to alternative therapies potentially Commentaries