In addition to Grace’s childhood-onset schizophrenia spectrum disorder diagnosis, she also has a generalized anxiety disorder diagnosis. So, while Grace’s positive symptoms are under control, she still has some negative symptoms, cognitive symptoms, and symptoms of anxiety. Controlling the positive symptoms in schizophrenia seems to be goal number one because a person can’t function if they’re psychotic. I’m not entirely sure how one controls a lack of behavior and feelings which is what the negative symptoms are.
Grace now exhibits a very low affect. At times, she glides around the house like a wraith. It used to be very unsettling, but it’s very familiar to me now. It does freak out the normies like the social workers who come to assess her. They look a little frightened of her. Her mood is not congruous with her affect. She appears apathetic, having no energy for what used to interest her, but this isn’t necessarily true. It’s just how she appears. Oftentimes, if you ask her how she is she’ll tell you that she feels well which is just odd because she looks terrible.
The part of her diagnosis that is exacerbating her negative symptoms which may kick off her positive symptoms is her anxiety. Anxiety is a monster, and it is hard to control. Stress makes anxiety worse. Stress also wakes up the sleeping dragon of schizophrenia. What can be done to control anxiety? I’ve been going around and around about this. Grace does receive services, and, while the services are good, it feels like it’s not the best fit. We’re not hitting the bulls-eye.
Grace, like so many of us, is easily triggered by small things. She can be moving at a good clip until one little thing sets her off, and then the whole family is affected by her crash. It is extremely stressful. We might be out enjoying a lovely day when, suddenly, Grace’s mood switches, and she’s standing in the middle of a venue looking like Creepy Susie.
It’s unsettling, disappointing, and, to be honest, hard on everyone. Of course, we all love Grace and want to help her, but the honeymoon is over. I’ve seen some eye rolls. I’m seeing the shoulders slump. “Do we have to leave now?” The resentment is building. The questions are going to come: “Why does everything have to revolve around Grace?”
That’s a fair question. My answer? It doesn’t.
So, last week, I took it up a notch with Grace because I wanted to know what her limits were. She was doing well. She was self-directing. Everyone was getting on, and then she wasn’t doing well. I don’t know what set her off, but her dark presence cast a gloomy pall over the rest of us. I took her into a vacant bedroom and talked to her. I wanted to know what had caused her mood to switch. I also wanted to know why it was so frequent. Lately, she has been particularly antagonistic towards Milly. Milly can scarcely breathe without Grace criticizing her. Milly is not going to put up with that so she dishes it back to Grace.
There’s nothing like having a house guest to open your eyes to relational dynamics.
Basically, I told Grace that she’s had about two years of therapy and skills training. What skills was she using in the moment to help herself deal with whatever was bothering her? No response. I also said that I understood her limitations, but I was going to practice assumed competence here. I was not going to enable her. Sure, she had a diagnosis. So what? She also had more invested in her success than most adults have so she needed to bring those skills to the table. Her therapist wasn’t coming into our home for hours every week for nothing. I expected her to use what she was learning.
“I can’t remember my skills! And I get anxious because I get bad thoughts. And then I get overwhelmed.”
That’s information I can work with. Cognitive symptoms are part of schizophrenia, and the earlier the onset the worse the cognitive decline. We can type out a list of her skills and put them on cards like a cheat sheet. That’s easy enough to remedy.
The “bad thoughts” are something altogether different. Is that anxiety or psychosis?
People with schizophrenia can experience a call to action wherein they will hear voices or even have an urge to do something that they intuit as coming from somewhere outside of themselves. This occurs during psychosis. It is said that a person has “insight” when they know that the voice or call to action is not real. Anxiety is a natural by-product of experiencing psychosis because one would be fearful of experiencing it again. “Is that person real? Am I really seeing this? I just heard a voice. Was that voice a real voice?” When you know that you’ve once experienced a reality that, to you, was very real but was, in fact, not real at all, then you will question reality and your perceptions of it frequently. This is the root of Grace’s anxiety. She questions her perceptions a lot and engages in checking behavior which looks like obsessive behavior. Did she really take her medications, or did she just imagine it?
I, therefore, wanted to come up with a strategy to help her. I am currently taking a Dialectical Behavior Therapy skills class with Eadaoin. It’s 25 weeks long, and we are learning, in great detail, DBT and how to apply it to our lives. What I noticed about Grace’s statement is that she had applied a judgment to her thoughts. She had “bad” thoughts. Not just thoughts. And the nature of the thoughts is what kicked off her anxiety. What if I could introduce her to mindfulness, a core component of DBT, without telling her what I was doing? What if I could teach her Step 1? Just Step 1?
“Grace, would you be willing to think differently about your thoughts? What if your thoughts, when you are not psychotic, are neither good nor bad. What if they are just thoughts. What if, instead of judging them, you just watched them go by like clouds? So, imagine yourself on the hammock looking up at the sky watching the clouds pass over you. You see a cloud shaped like an elephant. You don’t say that it’s cute or big or good. It’s just an elephant. You then see a ball. Then, a raindrop-shaped cloud. Then, a kitten. Then, a face. Then a cloud shaped like a horrible monster who frightens you.”
“I don’t like that!”
“Well, no, because normally that is not something that you want to see. There are intrusive thoughts that we don’t want to think, but now instead of applying a judgment to the cloud and labeling it as a bad cloud simply let it pass. ‘That’s a monster cloud.’ It’s neither good nor bad in this moment. It’s just a cloud. Then, you see another cloud shaped like a candy cane.”
“That’s hard, Mom.”
“Yes, it can be, but it’s not impossible. It’s just a new way to think about thoughts. We can be so attracted to one idea that we often don’t realize that there are other ways to think. Instead of judging our thoughts and categorizing them as good or bad, we can simply let them pass. They don’t have to be either. You can be an observer of your thoughts rather than a judge of them. The funny thing about doing this exercise is that once you start observing your thoughts, you will notice that you start to feel different in your body. You will start to feel less anxious because you aren’t assessing yourself all the time.”
Grace agreed to try this. This practice is called observing or wordless watching, and it is step one in practicing mindfulness. It is not easy, but it’s doable. I’ve been practicing mindfulness for a few years, and I can say that it’s worth learning. Your inner state of mind changes for the better as you increase your practice which changes your outer affect and relatability. As you learn to stop judging your thoughts you will find that you stop judging others which is, to me, a miracle.
Keep in mind, mindfulness is a practice which means that as you begin it will not come easily. The more you practice, the easier it gets.
Also, there are many, many mindfulness exercises, but here’s one that I find quite fun:
In addition to this, you can print mandalas which are fantastic for practicing mindfulness and a wonderful excuse for breaking out the markers, colored pencils, and crayons. Here are some useful links for free printable mandalas and a brief overview of the mandala: