Schizophrenia Bulletin vol. 42 no. 3 pp. 531–533, 2016
doi:10.1093/schbul/sbt119
Advance Access publication August 19, 2013
FIRST PERSON ACCOUNT
Schizophrenia, Maslow’s Hierarchy, and Compassion-Focused Therapy
Mark Ellerby
I have experienced psychosis for 20 years. The main symptoms are voices and delusions that interact and reinforce
each other. I have written a lot about my illness over the
years in a series of autobiograhical books called “The
Stages of Schizophrenia” (Chipmunka publishing 2007).
I have had numerous medications including risperidone
and clozapine as well as 2 years of cognitive behavioral
therapy. In 2005 I relapsed, and having tried many things
already, it was decided by my community psychiatric nurse
to refer me to a psychologist at my local (mental) hospital.
I have been having compassion-focused therapy (CFT).
I began to understand the process in terms of how we
might use compassion within the various parts of the
mental health system to help the self-growth of patients on
Maslow’s model of the hierarchy of need. This has been a
lengthy and ongoing process as I shall now describe.
We know from Maslow’s hierarchy of needs that safety
needs must be met before emotional needs and emotional
needs before self-esteem and esteem before self-actualization. From Gilbert’s CFT model (Paul Gilbert Compassion
Focused Therapy, Routledge 2010), we know that threat
interferes with our problem solving, insight, personality,
and emotions. The reason it does this is because the brain
needs to provoke a physical response to defend or protect
itself—the fight-flight response, submission, etc.
What has all this got to do with schizophrenia?
The 2 main symptoms of my schizophrenia are hearing
critical voices and having paranoid delusions.
This illness attacks self-development on the Maslow
tree in 5 key ways.
It seems that CFT can help with climbing the Maslow
tiers as follows:
TIER 1: Help may be needed to support basic needs
like cooking, keeping clean, and other household tasks.
Giving and receiving practical support are inherently
related to our care-giving mentality.
CFT focuses on the level of arousal by training breathing exercises, safe place imagery, and compassionate
image work. These are often taught at day centers, in the
form of relaxation classes, but as we shall see compassion
is rarely involved.
TIER 2: Sheltered Accommodation is just that ie sheltered and can contribute to the safety needs of service
users. Hospital wards can hinder recovery because the
patients in and nurses are not sharing compassionate
conversation and are left to watch the television. They do
not always feel safe-like places.
TIER 3: Compassion allows connectivity and empathy
toward other people and should be useful for generating
progress on the relational level. It plays a foundational
role in friendship and loving relationships and families
and is also a warm, pleasurable feeling created by our
soothing system.
•• This may need an institutional context, like day centers,
to be facilitated because people with schizophrenia can
be stigmatized and socially isolated. Day centers are
places where people can talk to each other and develop
compassion through witnessing each others suffering.
From here, friendships and relationships can develop
strengthening the emotional level of the tree still further. Compassion may give patients the emotional
strength to support work and independent living outside the mental health system, which is the ultimate aim
of such places.
•• The key to understanding this could be seen as
providing more of a “family/affiliative” atmosphere on
inpatient wards. Less emphasis on the medical model
may be helpful. Instead of patients getting drugged on
tablets, active and interactive means of recovery may
be understood to be possible. Compassionate training
on the part of nurses and keeping the patients would
overcome the threat system.
•• Schizophrenia often impairs our motivation to look
after ourselves, and our physiology is dominated by
anxiety (Maslow’s first tier of physiological needs).
•• Paranoid delusions are frightening and make us feel
unsafe in the world (Maslow’s second tier of safety).
•• Delusions make it difficult to trust people (third tier of
belonging).
•• Hearing critical voices attacks our self-esteem (Maslow’s
fourth tier of self worth).
•• It is difficult to put energy into creativity when attention is pulled to threats (Maslow’s fifth tier of achieving
potential).
© The Author 2013. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. All rights reserved.
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M. Ellerby
•• Maintaining close family support (particularly with
compassionate relatives) is a way of building emotional strength against voices and delusions and also
helps develop the emotional tier of the Maslow tree
in profound ways. If family contact is restricted by
wards, this is going to be more difficult. At the extreme,
some patients may be cut off from families and friends
because they form the focus of their paranoia on childhood trauma or being a dysfunctional family. I think,
there may well be a myriad of other factors in family
life that might also be relevant. In my case, any differences in my family were put aside, however, and the
need for love and care took over instead.
TIER 4: Compassion helps esteem needs by reducing our
self-critic. Compassion helps relationships by reducing
our fears of what others think of us. Using the compassion in soothing the fear caused by the paranoid delusions
opens up different possibilities for action and reflection.
Dealing with the self-critical voices removes a barrier to
esteem and opens up the possibility of reaching potential
at the self-actualization level. Gilbert states, it is easier to
give compassion to others than oneself, so as we give it to
others on the emotional tier of the pyramid, we can only
then get it back from them and so progress to the fourth
tier of the pyramid by then going to give this compassion
to ourselves. This was demonstrated to me in the CFT
group I attended: we had to look in the eyes of another
person in the group and respond compassionately to their
suffering. They then did the same to me, and finally after
this, it was possible to give it to ourselves. Without giving
compassion to ourselves, as provided by CFT, the therapeutic aims and value of day centers are going to be very
limited and the crucial step from the third to the fourth
tier would be very difficult.
Let us also now explore my story in more detail as an
example of some ways in which CFT and Maslow can
help with schizophrenia on my own journey from onset
to recovery and then go on to look at some other implications of this.
My Story
Crucially CFT should, in my experience, take place
within an institutional context, stage by stage. By outlining this, we can see that CFT is going to be invaluable to
the mental health system as a whole including some governmental policy making like providing housing, tackling
stigma, and finding employment.
Homelessness is sometimes the trigger for or is a result
of a mental illness. Maslow’s basic needs include shelter
and safety, so we find that Sheltered Accommodation
can be the answer. There are staff there who can prompt
us to take meals, keeping on top of housekeeping and
help keep us functional. Without this there may be some
self-neglect and inability to feed or otherwise look after
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ourselves. As the benefits system recognizes, people may
need prompting to look after our basic needs and that
takes someone on hand to help, like a mental health project worker.
Early in my illness, I thought that the neighbors were
spying on me, so I went off into unpopulated areas to get
away from them. I wandered around the countryside at
night, even through rain and blizzards. It was only after
I moved into sheltered accommodation that I began to
be more aware of the fear and safety needs once my basic
needs were being cared for. At this point, I didn’t dare
go out of my room even as my paranoia made me afraid
of everyone. I was able to talk about my fears to project
workers and staff, and this helped keep me calm sometimes. They became people I could trust and so they were
able to reassure me and so with help with overcoming the
second safety tier of safety needs in Maslow’s pyramid.
Sheltered accommodation is just that. Living in a project is sheltered from the big bad world, and it provides
a 24/7 environment within which safety needs and emotional support can be given to help self-growth of people
with a mental illness. I feel, compassion too would have
helped with and enhanced the stated aim of “emotional
support” in such places. Furthermore, I think compassion can help cope with the fear and self-blame caused
by stigma. Society blames patients for their own illness
so that cracking up under pressure is equated with not
having the strength to prevent being driven mad. This is
true for schizophrenia and depression, both of which are
stress induced. We can add to our sense of self-esteem
by having compassionate understanding for our situation rather than blaming ourselves for it. So sheltered
accommodation was a stepping stone to the third tier of
Maslow’s pyramid, which was then further reinforced by
day centers. Here, I met new friends who accepted me. My
attention shifted to pleasure and was increased through
meeting new friends and enjoying the courses on offer.
Whilst having cognitive behavioral therapy, a support
worker was put in place to go out with me, and I was
gradually exposed to the fear I had of going out. Other
coping strategies were also put in place to help such as
breathing, meditation, and ways of distracting myself
with various forms of entertainment. None of this was
as promising as reducing the fear through compassionate
engagement. However, the CFT psychologist suggested
that embodying courage and wisdom from the compassionate image work would help with my motivation to get
out of my room. I noticed that sitting at home focusing
attention on the voices was making things worse.
That just leaves getting a job and the sense of
purpose that can bring. I think this hits on the fourth
tier of Maslow’s Hierarchy, that of self-esteem, which
I think having a sense of purpose can contribute to.
Some schizophrenics have been quite successful such as
John Nash in the film A Beautiful Mind and in the US
academic Elyn Saks. Employment is good within CFT
Compassion-Focused Therapy
too because it allows the possibility of mastering new
skills progressively as we embark on the climbing the
career structure and, perhaps, more so than just getting
qualifications at day centers and the status and esteem
attached to that. Kristen Neff found that self-esteem,
Maslow’s fourth tier, depends a lot on our position in
society and how far up we are in the social hierarchy. This
is going to be particularly problematic for mental health
patients because few of them have the opportunity to
work. My psychologist noticed that when I talked about
some of my books and issues I knew about, I became
much less terrified and able to think more clearly. This
motivated me to write again and set goals. However, it is a
challenge for me not be define my worth by such activity.
Sometimes I feel that writing is a way of atoning for sins.
CFT is helping me feel worth for my own sake rather than
be driven by fear. The voices contribute to the self-doubts
on my ideas. Interestingly, developing compassion itself
can be a source of self-esteem. It is very rewarding for
me to develop sensitivity and care to other people. We
may feel better about ourselves by developing a caring
feeling toward others and begin to value the way we react
to other as human beings.
As far as the final tier of the pyramid goes, it is difficult to have the energy to be creative and even motivated
to reach potential when one has a mental illness. My illness took me on a different life path whilst I was doing
my PhD. Yet, it can also open up possibilities. I would
not be writing this were it not for my illness, and I have
adjusted to the changes. I am not unhappy. That just
leaves the question as to whether there are any examples
of Maslow’s self-actualizers who have schizophrenia?
I believe this should be the overall goal of the mental
health system and the goal of its patients. We should not
give up hope of this just because we have schizophrenia
and should strive to attain this. Compassion has a role
to play at the apex of Maslow’s pyramid in being at ease
with the world. What I have noticed is the following:
•• When I eventually calm down, I return to a normal
emotional state and go from threat to safeness … and
vice versa when frightened.
•• This seems to point to the fact that climbing the Maslow
tree may be possible with schizophrenia.
•• Compassionate support from services and family will
help this journey.
•• CFT has given me some hope.
As I have explained the progression in experiential terms,
I believe that compassion can help at every stage of this
institutionalized process, but it needs to be more widely
practiced in services. The problem here is the complexity
of the therapy and the cost of the required psychological
help? Yet, even this has a reply in that being on drugs and
medicines is also expensive, so we need to do some balancing about the costs here.
Some Implications
So what is the importance about this story? I think there
a few possibilities here:
•• I understand that in CFT, it helps with traumas, relationship problems, and fears created by schizophrenia, which at least opening up certain possibilities of
patient self-growth.
•• CFT is a way of positively applying holistic approaches
to schizophrenia where we try to enable all sorts of selfgrowth practices to help patients develop.
Conclusions
In my autobiographical writings entitled The Stages of
Schizophrenia (Chipmunka Publishing 2007), I have narrated my story and experience of mental illness as going
through a series of stages: from first symptoms of the
illness and loss of home to the group environments of
hospital ward and sheltered accommodation and finally
to day center and their help with getting back into education and anonymously with my new found friends within
the society. Looking back, I can now see that compassion could have greatly helped this process, and wish
I had heard of it in decades gone by. This therapy makes
sense to me and should be tried, in my view, much more
widely. This is especially important given the treatment
resistance of the illness to many medical and cognitive
approaches to the illness. There is hope here not only for
some cessation or reduction in the severity of the illness
but also for the self-growth of the patient living within
the mental health system.
Acknowledgments
I would like to thank Dr Angela Kennedy for her insight
and expertise in helping develop this article and for being
willing to discuss the theoretical and practical basis of
the therapy with a patient. I am also indebted to Paul
Gilbert’s handbook on CFT that has greatly enlightened
me on how this therapy works in theory and practice.
Furthermore, I would like to acknowledge all the help
from my friends and family and mental health professionals for all the care I have receive and without whom
this therapy would not have been so effective.
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