No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Building bridges to observational perspectives: A grounded theory of therapy processes in psychosis
Abstract
This study set out to explore therapy processes in psychosis with an initial focus on reflexivity and how this might be expressed in therapy conversations.
Leiman's (2000) definition of reflexivity was used as a starting-point for an exploratory investigation of the use of language as reflective activity. Grounded theory was chosen as an appropriate methodology to distil an explanatory account across the qualitative data collected.
Six psychologist-client pairs supplied three tapes of therapy sessions spread out across the course of therapy. Each participant was separately interviewed on two occasions to ascertain their views of therapy and of the emerging grounded theory.
A grounded theory was developed conceptualizing the processes and activities in psychological therapy in psychosis.
Building bridges to observational perspectives summarizes the core process in psychological therapy in psychosis. Therapy in psychosis is understood as intimately linking the social and internal world in a dialogical process aimed at enhancing the client's functioning in the social world rather than at specifically developing the private mental experience of reflexivity or mentalizing.
... Several clients experienced the therapist as a 'healer' who was able to make them feel 'better. ' Dilks, Tasker & Wren (2008) investigated therapy processes in psychosis. They found that after psychological intervention clients experienced more confidence: ...
... [ them that their experiences were not true. In 'building bridges to observable perspectives' (Dilks et al, 2008) the authors reflect on how the psychologists appeared to be continually lending alternative observational perspectives to the client, enabling the client to consider different perspectives to explain their experiences. Messari and Hallam (2003) found that two clients in their research were aware of their therapists' position regarding their psychotic experiences, even when they were trying to appear 'open minded.' ...
... In the Messari & Hallam (2003) study, clients felt the therapist took them seriously; this enabled them to trust the therapist. In 'building bridges to observational perspectives,' (Dilks et al, 2008) the authors identified that a main therapy activity was the 'doing relationship' ...
... There has been recent work emphasizing the therapist's role in assisting a person experiencing psychosis to make sense of this experience in a manner that enhances a sense of agency and self-worth, offers hope for the future, and allows the processing of distress (see Dilks, Tasker, & Wren, 2008;Lysaker & colleagues' work, e.g., Lysaker and Buck, 2006;Lysaker and Daroyanni, 2006;Lysaker, Lancaster, & Lysaker, 2003;Lysaker, Wickett, Campbell, & Buck, 2003). Examinations of personal accounts of psychosis also highlight the importance of making sense of troubling experiences in recovery from psychosis (e.g., Davidson, 2003;Dilks, Tasker, & Wren, 2010;Hirschfeld, Smith, Trower, & Griffin, 2005). ...
... This position actually seems consistent with both Strauss and Corbin's (1998) and Glaser's (1978) more detailed descriptions of their approaches to grounded theory. This paper specifically reports on a subset of the findings from the grounded theory model of therapy processes in psychosis described more fully in Dilks et al. (2008Dilks et al. ( , 2010. Detailed findings relating to specific therapist activities are described separately here in order to allow a fuller consideration of these activities. ...
... The grounded theory of therapy processes in psychosis is reported in detail in Dilks et al. (2008) and the analysis of the personal accounts data is described in Dilks et al. (2010). The current report focuses on aspects of the analysis relating specifically to therapist activities and describes findings from the analysis of therapy session tapes, interviews with the therapist and client sample, and the additional set of interviews with psychoanalytically aware psychologists. ...
Objectives. This paper reports on a subset of findings from a wider ranging grounded theory analysis of therapy and recovery processes in psychosis. It describes therapist activities involved in maintaining an observational perspective during therapy and the links between these and other therapist activities.
Design. Grounded theory was used to examine the qualitative data collected.
Methods. An initial sample of 19 taped therapy sessions and 23 interviews with psychologists and their clients was collected. This sample was extended through the collection of three further interviews with psychoanalytically aware psychologists. The data were analysed using grounded theory.
Results. A grounded theory model of therapy processes in psychosis was developed that conceptualized therapist actions as providing an observational scaffold to support the client's efforts in moving to new perspectives on their situation. Consistent with the understanding of the core therapy activity as a dialogical process, this set of therapist actions was understood as occurring alongside other therapist activities involved in managing emotion and building a relationship in therapy.
Conclusions. The central activity of therapy in psychosis was understood as a dialogical process continuously negotiated between therapist and client in conversation and was conceptually summarized in the grounded theory as ‘building bridges to observational perspectives’. However, the active and strategic efforts of psychologists to sustain the dialogue implied a particular assumption of responsibility for maintaining this process. In particular, therapists appeared to be ‘working to maintain observational perspectives’, ‘managing emotion’, and ‘doing relationship’ during the therapy conversation as part of the joint effort with clients to build bridges to new observational perspectives on distress and psychosis.
... Rose et al., 2004. Τέλος, οι συνέπειες των ψυχολογικών θεραπειών φαίνεται να είναι περισσότερο θετικές, αφού η ψυχοθεραπεία φάνηκε να βοηθά στη δημιουργία συνδέσεων μεταξύ του εσωτερικού και του κοινωνικού κόσμου (Dilks et al., 2008), η εκπαίδευση στην ενσυνειδητότητα βοηθά στην επίγνωση και αποδοχή, και επομένως στην αποτελεσματικότερη διαχείριση, των ψυχωτικών συμπτωμάτων (Abba et al., 2008), ενώ στους παράγοντες που ενισχύουν την αποτελεσματικότητα της γνωστικής-συμπεριφορικής θεραπείας της ψύχωσης περιλαμβάνονται η ικανότητα αποσύνδεσης από αρνητικές σκέψεις, η ικανότητα λογικής σκέψης και η θεραπευτική συμμαχία (McGowan et al., 2005). ...
Η Μονογραφία αυτή συνεισφέρει στη βιβλιογραφία για την ανάπτυξη ενός κοινοτικά και κοινωνικά προσανατολισμένου συστήματος ψυχικής υγείας. Οι δεκαετίες της ψυχιατρικής μεταρρύθμισης στην Ελλάδα συνέβαλαν ουσιαστικά στην προαγωγή και την προστασία των ανθρωπίνων δικαιωμάτων των ατόμων με ψυχικές διαταραχές, και στην ποιότητα ζωής τους. Τα τελευταία χρόνια, το κοινοτικό μοντέλο φροντίδας ενισχύεται από νέες προσεγγίσεις, όπως το μοντέλο της ανάρρωσης που δίνει έμφαση στην ενδυνάμωση των ατόμων με ακραίες ψυχικές εμπειρίες αναγνωρίζοντας τις προσωπικές τους εμπειρίες ως πηγή γνώσης και νοηματοδότησης. Η Μονογραφία υπηρετεί τις σύγχρονες αυτές προσεγγίσεις, κομίζοντας τη διεθνή βιβλιογραφία αιχμής στο συγκεκριμένο πεδίο. Στο πρώτο μέρος, αναπτύσσεται μια επιστημονικά τεκμηριωμένη ανασκόπηση της σύγχρονης βιβλιογραφίας αναφορικά με την κατανόηση και αντιμετώπιση της ψύχωσης. Στο δεύτερο μέρος, παρουσιάζονται ευρήματα μιας πρωτότυπης, πρωτογενούς έρευνας που εφάρμοσε αφηγηματική βιογραφική προσέγγιση για την ανάδειξη των μαρτυριών των ανθρώπων με ψύχωση. Μέσα από τις μαρτυρίες των συμμετεχόντων, αναδεικνύονται οι εμπειρίες της ζωής πριν την εμφάνιση της ψύχωσης και οι κοινωνικοί παράγοντες που πιθανόν συντέλεσαν σ’ αυτήν. Χαρτογραφούνται, επίσης, οι τρόποι με τους οποίους βίωσαν, νοηματοδότησαν και διαχειρίστηκαν τις ψυχωτικές τους εμπειρίες. Με δεδομένη τη δυναμική ενσωμάτωση νέων επιστημονικών πεδίων, όπως της κοινοτικής κλινικής ψυχολογίας και της κοινωνιολογίας της υγείας και της ασθένειας, στα Προπτυχιακά και στα Μεταπτυχιακά Προγράμματα Σπουδών, η Μονογραφία αναμένεται να αποτελέσει έναν χρήσιμο βιβλιογραφικό πόρο σε φοιτητές/-τριες, ερευνητές/-τριες και επαγγελματίες που επιθυμούν να εργαστούν προς μια ανθρωπιστική κατεύθυνση κατανόησης και αντιμετώπισης του ψυχικού πόνου και να αναπτύξουν επαγγελματικές πρακτικές υποστήριξης της ανάρρωσης, κάτι το οποίο αποτελεί εκπεφρασμένο στόχο και ζητούμενο για τους σύγχρονους επαγγελματίες ψυχικής υγείας.
... Results indicate participants valued the opportunity to develop adaptive coping strategies, ways of responding differently to the voices and new ways of thinking. Similarly, previous research has found changes in perspectives of clients to be a core process in psychological therapy for psychosis (Dilks et al., 2008). It has been suggested from voice hearing research and cognitive theory that this process of meaning making can alleviate distress (Morrison, 2001;Romme & Escher, 1989). ...
Background
Cognitive Behavioural Therapy for voice hearing (CBTv) has been shown to be effective at reducing distress. However, it is unclear why voice hearers might deteriorate or continue to benefit post-intervention. This study aimed to explore therapeutic change processes following CBTv.
Methods
A critical realist, grounded theory methodology was utilised. Individual interviews were conducted with 12 participants who had experienced distressing voice hearing and had completed a CBTv intervention in the last 3–12 months. Participants were recruited from a specialist hearing voices service.
Results
Three categories were found to be facilitative of positive change within CBTv: “New Ways of Managing”, “Overcoming Challenges” and “Gaining New Perspectives”. Five categories denoted the maintenance or furthering of positive change following intervention: “Having a Sense of Control”, “Standing on My Own Two Feet”, “Voices Are Just Part of My Life”, “Investing in Sustaining Relationships”, and “Rediscovering and Developing Identity”. Challenging circumstances faced by participants are also incorporated into a model for maintaining change following CBTv.
Discussion
The model adds to current literature on change processes occurring within and after CBTv. The results support the need for those working with voice hearers post-therapy to focus on rebuilding social relationships, meaning making and identity.
... Additionally, recent work has also emphasised the therapist's role in supporting clients to approach their experiences in a meaningful manner. This has been shown to enhance a sense of agency and the processing of distress (e.g.Dilks, Tasker, & Wren, 2008;Lysaker, Wickett, Wilke & Lysaker, 2003). Along similar lines, all participants in this study have provided numerous examples in explaining how their approach towards the meaningfulness of their clients' experiences have assisted them in handling their distress while it also cultivated a climate of cooperation in the therapeutic relationship.Participants' emphasis on how their clients' past and present lived experiences and relationships have influenced the development and maintenance of their distress and how this was related to the impoverishment of their significant relationships were also stressed. ...
New exciting literature that points to the significance of considering intersubjective processes in therapeutic work with people diagnosed with psychosis has been recently developed in the realms of phenomenological psychology and psychiatry. However, the research literature reveals an emphasis towards the exploration of clients’ processes and an underestimated inclination towards the in-depth exploration of therapists’ experiences that work from an intersubjective/interrelational perspective with this client group. Given this particular limitation, we therefore need a more detailed exploration of what this work is like, and how therapists make sense of this work considering this intersubjective turn. This project has therefore attempted to shed light on the intersubjective processes of psychotherapy for psychosis from the therapists’ point of view while emphasising how the therapeutic praxis can be grounded upon firm existential-phenomenological principles. The study explored the subjective experiences of six counselling psychologists and/or therapists who identified themselves as working intersubjectively with psychosis. After careful consideration, Interpretative Phenomenological Analysis (IPA) was employed as the most suitable methodology in order to explore the interviews and to gain insight into participants’ lived experiences of their relationships with clients. The analysis of data revealed four key themes: the primacy of sense-making, a relational approach to therapy, therapists’ processes in the rupture of relatedness and the lived experience of being-with. Despite the congruence with the limited literature on therapists’ lived experiences of their intersubjective work with psychosis, the results of this study also shed light on some neglected areas of consideration with regards to the therapeutic process, while encouraging the consideration of existential/phenomenological contributions towards both the understanding and clinical praxis of the psychotherapy for psychosis. This piece of work consists therefore of a significant contribution to the limited literature on phenomenological and intersubjective work with psychosis and is an essential addition to counselling psychology literature.
... Additionally, recent work has also emphasised the therapist's role in supporting clients to approach their experiences in a meaningful manner. This has been shown to enhance a sense of agency and the processing of distress (e.g.Dilks, Tasker, & Wren, 2008;Lysaker, Wickett, Wilke & Lysaker, 2003). Along similar lines, all participants in this study have provided numerous examples in explaining how their approach towards the meaningfulness of their clients' experiences have assisted them in handling their distress while it also cultivated a climate of cooperation in the therapeutic relationship.Participants' emphasis on how their clients' past and present lived experiences and relationships have influenced the development and maintenance of their distress and how this was related to the impoverishment of their significant relationships were also stressed. ...
New recovery-oriented literature points to the significance of considering dialogical and interrelational approaches to both the conceptualisation and psychotherapy of psychosis. This literature encompasses a broad spectrum - including phenomenological, integrative, humanistic, psychoanalytic, narrative and cognitive-behavioural approaches. Despite the emphasis on intersubjective processes inherent in the therapeutic process, there has been a tendency to focus on the exploration of clients’ processes, while an exploration of therapists’ experiences remains somewhat absent. We, therefore, need a more detailed exploration of what this work is like, and how therapists make sense of this work considering this intersubjective turn. This paper discusses findings from a recently completed phenomenological exploration of the experience of therapists working intersubjectively with psychosis.
... είας από τα άτομα που έχουν υποβληθεί σε αυτήν φαίνεται να είναι πολύπλοκη μεν, κατεξοχήν αρνητική δε (Johnstone, 1999. Rose, Fleischmann, & Wykes, 2004, ενώ, σύμφωνα με τους συμμετέχοντες, η ψυχοθεραπεία συμβάλλει στην αποδοχή, την καλύτερη κατανόηση και την αποτελεσματικότερη διαχείριση των ψυχωτικών συμπτωμάτων (Abba, Chadwick, & Stevenson, 2008. Dilks, Tasker, & Wren, 2008. McGowan, Lavender, & Garety, 2005. ...
This paper provides a methodological review of qualitative studies on the lived experience of psychosis. It aims to present the main research trends on psychotic experience and to assess their usefulness and appropriateness for examining the role of social factors in the emergence, experience and management of psychosis. The following trends are presented: (a) the phenomenological approach, which aims to identify the essence of psychotic experience, (b) the narrative and dialogical approaches, which focus on the constitution of the self in psychosis through the examination of self-narratives, (c) the social constructionist approach, which, through analysing the discourse of persons in distress, examines the construction of mental distress,and finally (d) empirical studies employing thematic type qualitative analysis on interviews with persons in distress in order to highlight their experiences and views regarding various aspects of their life with psychosis. For each of the approaches, the paper addresses: (a) its epistemological paradigm, (b) the view of psychosis and mental distress adopted, (c) the research methodology used regarding data collection and analysis, (d) the main findings and conclusions, and (e) the role attributed to social factors and processes.
... Using the method of grounded theory, Dilks et al. (2008), identified activities of the therapist that included 'opening up views', 'negotiating shared understanding', 'doing relationship' and 'managing emotion'. These therapist activities were reported by the client to be linked to 'opening up new possibilities', 'processing distress', and 'enhancing agency and selfworth'. ...
Mentalization has been clearly defined in the literature as a relational concept and yet in surveys and transcript-based measures it is almost universally treated as an individual capacity. That approach has value but may not capture the emergent nature of mentalization, as it is jointly constructed within a relational context. We report here on a critical evaluation of measurement approaches commonly used to conceptualize and assess mentalization and argue for the value of conversation analysis (CA) as an alternative approach. A variety of approaches have been shown to have utility in assessing mentalization as an individual capacity. We illustrate how conversation analysis allows for an in-depth-analysis of mentalization as it is co-created across different contexts in real-life therapy sessions. This method of analysis shifts the focus from content to process. Conversation analysis is a potentially valuable tool to support training, to assess treatment integrity, and to improve outcomes with mentalization-based interventions.
... είας από τα άτομα που έχουν υποβληθεί σε αυτήν φαίνεται να είναι πολύπλοκη μεν, κατεξοχήν αρνητική δε (Johnstone, 1999. Rose, Fleischmann, & Wykes, 2004, ενώ, σύμφωνα με τους συμμετέχοντες, η ψυχοθεραπεία συμβάλλει στην αποδοχή, την καλύτερη κατανόηση και την αποτελεσματικότερη διαχείριση των ψυχωτικών συμπτωμάτων (Abba, Chadwick, & Stevenson, 2008. Dilks, Tasker, & Wren, 2008. McGowan, Lavender, & Garety, 2005. ...
This paper provides a methodological review of qualitative studies on the lived experience of psychosis. It aims to present the main research trends on psychotic experience and to assess their usefulness and appropriateness for examining the role of social factors in the emergence, experience and management of psychosis. The following trends are presented: (a) the phenomenological approach, which aims to identify the essence of psychotic experience, (b) the narrative and dialogical approaches, which focus on the constitution of the self in psychosis through the examination of self-narratives, (c) the social constructionist approach, which, through analysing the discourse of persons in distress, examines the construction of mental distress, and finally (d) empirical studies employing thematic type qualitative analysis on interviews with persons in distress in order to highlight their experiences and views regarding various aspects of their life with psychosis. For each of the approaches, the paper addresses: (a) its epistemological paradigm, (b) the view of psychosis and mental distress adopted, (c) the research methodology used regarding data collection and analysis, (d) the main findings and conclusions, and (e) the role attributed to social factors and processes.
Στην εργασία αυτή επιχειρείται μια μεθοδολογική ανασκόπηση ποιοτικών μελετών της βιωμένης εμπειρίας της ψύχωσης. Στόχος είναι η παρουσίαση των κεντρικών ερευνητικών ρευμάτων της ψυχωτικής εμπειρίας και η αποτίμηση της χρησιμότητας και καταλληλότητάς τους για τη μελέτη του ρόλου των κοινωνικών παραγόντων στην εμφάνιση, βίωση και διαχείριση της ψύχωσης. Στην εργασία παρουσιάζονται: (α) η φαινομενολογική προσέγγιση, που στοχεύει στον προσδιορισμό της ουσίας της ψυχωτικής εμπειρίας, (β) η αφηγηματική και διαλογική προσέγγιση, που επικεντρώνονται στη συγκρότηση του εαυτού στην ψύχωση, μέσω της εξέτασης των χαρακτηριστικών των αφηγήσεων του εαυτού, (γ) η κοινωνική κονστρουξιονιστική προσέγγιση, που μέσω της ανάλυσης του λόγου ατόμων με εμπειρία ψυχικού πόνου εξετάζει την κοινωνική κατασκευή του ψυχικού πόνου, και τέλος (δ) εμπειρικές μελέτες που χρησιμοποιούν θεματικού τύπου ποιοτική ανάλυση συνεντεύξεων με άτομα με εμπειρία ψυχικού πόνου, προκειμένου να αναδείξουν τις εμπειρίες, απόψεις και θέσεις των ατόμων αυτών σχετικά με ποικίλες πτυχές της ζωής με την ψύχωση. Σε καθεμία από τις προσεγγίσεις εξετάζονται: (α) το επιστημολογικό παράδειγμα που υιοθετείται (β) η θεώρηση της ψύχωσης, και του ψυχικού πόνου εν γένει, (γ) η ερευνητική μεθολογία που ακολουθείται, αναφορικά με τη συλλογή και την ανάλυση του ερευνητικού υλικού, (δ) τα κεντρικά ευρήματα και συμπεράσματα των μελετών, και (ε) ο ρόλος που η κάθε προσέγγιση αποδίδει στις κοινωνικές παραμέτρους και διεργασίες.
... At one point in therapy, the latter therapist made a seemingly offhanded comment on the client's sweater, which indeed helped the alliance-building in a creative way. With the aim of describing the meaning-construction process in psychosis, Dilks, Tasker, and Wren (2008) used grounded theory and found several ways clients may engage in constructing meaning, which helped them in the dialogue with the therapist. Creating meaning is here a circular process implying both client and therapist contributions. ...
Therapist responsiveness is defined as therapist behavior being influenced by emerging context. Responsiveness is ubiquitous and creates serious problems for a ballistic, cause–effect understanding of how psychotherapy works. This conceptual literature review examines ways psychotherapy researchers have constructively engaged the responsiveness problem. We note classical approaches to the responsiveness problem and review all available citations of the formulation of the problem by Stiles, Honos-Webb, and Surko (1998, p. 439), focusing on proposed solutions. We identified N = 58 studies that cited the 1998 article and engaged with the responsiveness problem. These along with additional engagements with the responsiveness problem identified by us and by colleagues were reviewed. We distinguished six categories of ways researchers have addressed the responsiveness problem: (a) demonstrating effects of responsiveness, (b) measuring responsiveness quantitatively, (c) describing responsiveness qualitatively, (d) using evaluative measures, (e) developing responsive clinical interventions, and (f) extending responsiveness concepts to related domains. There are ways to engage the responsiveness problem that are scientifically productive. However, appropriately engaging the problem may require some psychotherapy researchers to ask different questions than they have previously asked.
... rnay, 2009. The evaluation of ECT by persons subjected to it appears to be both complex and overwhelmingly negative (Johnstone, 1999. Rose, Fleischmann, & Wykes, 2004, while, according to participants, psychotherapy contributes to acceptance, better understanding and more effective management of psychotic symptoms (Abba, Chadwick, & Stevenson, 2008. Dilks, Tasker, & Wren, 2008. McGowan, Lavender, & Garety, 2005. ...
During the last decades there has been increasing research interest in examining mental disorders from the perspective of those who experience them, mainly though the use of qualitative methodologies, in an attempt to grasp the lived experience of these disorders, the ways in which they are understood and managed by those who experience them, as well as their effects on people's lives. This talk attempts a methodological review of qualitative studies of the lived experience of psychosis, which has been conducted as part of a research project on the role of socioeconomic inequalities in the emergence, experience and management of psychosis. I will present (a) the phenomenological approach, which aims to define the essence of the psychotic experience, (b) the narrative and dialogical approach, which focuses on the constitution of the self in psychosis, through examining the characteristic features of self narratives, (c) the social constructionist approach, which through discourse analyzing the talk of people with experience of psychosis examines the social construction of distress, and (d) qualitative empirical studies which employ versions of thematic analysis to analyse interviews with people in distress, in order to highlight their experiences and views regarding various aspects of life with psychosis. For each of the approaches I examine the view of psychosis adopted, the research methodology employed, the main research findings and conclusions, as well as the role accorded to social factors and processes in the emergence, experience and management of psychosis.
... Growing evidence has highlighted the importance of meaning-making as an important coping strategy with which individuals with psychosis address the significant life disruption that accompanies the onset of their illness. [19][20][21] Moreover, facilitation of meaning-making, including cognitive evaluation of beliefs about one's psychosis, 22 has been hypothesized to be a key psychotherapeutic mechanism through which it can promote positive outcomes among individuals with psychosis. 23 Thus, the same neurological dysfunction that may lead to the experience of distorted auditory perceptions may also contribute to the coping and recovery efforts of individuals with first-episode psychosis. ...
AimAuditory hallucinations are hypothesized to be based in distorted sensory perceptions, with increasingly distorted perceptions of reality possibly prompting the first psychotic phase of schizophrenia spectrum disorders. Our goal was to examine the association between distorted auditory perceptions and psychotic symptomatology, social functioning and quality of life among individuals with first-episode psychosis.Methods
Forty individuals with first-episode psychosis completed assessments of distorted auditory perception, psychotic symptomatology, social functioning and quality of life.ResultsBoth negative (greater symptomatology) and positive clinical correlates (better quality of life) were associated with greater distorted auditory perceptions.Conclusions
Our findings suggest that distorted auditory perceptions are associated with both positive and negative clinical correlates among individuals with first-episode psychosis. These results highlight the potential clinical importance of balancing the goal of symptomatic reduction with the need to maintain healthy coping strategies that may be biologically and psychologically entwined with the symptoms of psychosis, themselves.
... Research in other therapies has demonstrated that systematic reporting of clients' experience of therapy can provide a greater understanding of therapy processes and applications to particular populations, potentially leading to the further refinement of therapy (Elliott, 2010). Qualitative client interviews have been successful in investigating components of therapy (Allen, Bromley, Kuyken and Sonnenberg, 2009; Messari and Hallam, 2003; Dilks, Tasker and Wren, 2008; McGowan, Lavender and Garety, 2005) and thematic analysis provides for identification, analysis and reporting on themes within the data (King and Horrocks, 2010). As yet little research has investigated ACT for psychosis (ACTp) from a client perspective. ...
Background:
There is limited research on the applicability and effectiveness of Acceptance and Commitment Therapy (ACT) for people experiencing psychotic disorders. Clinical trials suggest ACT may be efficacious in reducing distress and rehospitalization rates in psychosis. Mindfulness and reduced literal believability of thought content have been associated with reduced distress for this population.
Aims:
To better understand ACT for psychosis, this study investigated clients' perspectives of the hypothesized active therapeutic processes of ACT.
Method:
Semi‑structured interviews, conducted with nine adults diagnosed with schizophrenia or schizoaffective disorder and persistent positive symptoms, were analysed thematically.
Results:
Four themes emerged: Usefulness of therapy; Changes attributed to ACT; Understanding of therapy; and Non-specific therapy factors. All participants found therapy useful and recommended ACT. Mindfulness, defusion, acceptance and values work were described as the most useful therapy components and contributing to positive changes. Self-rated frequency of symptoms did not change; however a reduction in the intensity and distress associated with symptoms was reported. Non-specific therapy factors were deemed useful by participants but not directly related to outcome.
Conclusions:
These findings are consistent with the theoretically defined underlying active processes of ACT and are relevant for this population. The findings also indicate important clinical implications for ACT for this client group: greater attention to the client connecting metaphors and concepts to the intended meaning may be valuable; caution should be used with some mindfulness and defusion techniques for intense experiences; and values work may be particularly useful for this population.
... At the change-promoting stage, clients are helped to take a critical distance from their schemas, find different ways to think about problems, imagine creative solutions to conflicts, construct a broader repertoire of self-with-other representations, and acquire flexible and sophisticated problem-solving skills, including the use of a mature theory of the others' mind. At this point in therapy, the therapist and patient should try to engage in a dialogue in which they can switch perspectives, learning together by seeing things from different vantage points, until adaptive representations of the self, the others, and the problems hampering agency and the pursuit and fulfilment of patients' goals are achieved (Dilks, Tasker, & Wren, 2008;Dimaggio, Hermans, et al., 2010). ...
Many persons with personality disorders (PD) have problems contemplating mental states and using psychological knowledge to cope with their suffering and solve social problems, the skill termed metacognition in this article. Therapists can focus on metacognitive dysfunctions in order to tailor PD treatment to clients' metacognitive skills.
To briefly summarize procedures for promoting clients' abilities to define problems in mentalistic terms and use this knowledge to develop new paths towards living an adapted social life, within the context of a continuous regulation of the therapy relationship.
Qualitative analysis of session transcript excerpts from a good-outcome case treated with metacognitive interpersonal therapy.
A therapeutic focus on metacognitive dysfunctions and a regulation of the therapy relationship can lead to improvements in symptoms and interpersonal functioning. The possibility of generalizing the procedure and testing it empirically is discussed.
This study sought to understand how the experience of family interventions (FI) for psychosis helped family members to develop their thinking about their attachment experiences and the attributions made about a relative, and how these discussions helped to inform their understanding about problem‐maintaining cycles, that is, the interactional way in which difficulties could be maintained. Ten individuals who had attended an FI service participated in a semi‐structured interview. The transcript analysis used interpretative phenomenological analysis. The analysis yielded four themes: a supportive therapeutic relationship and safe therapeutic space; understanding patterns of relating and identifying when family interactions become unhelpful; making sense of psychosis and developing a sense of agency. The FI was experienced as helpful in bringing about changes in the way family members construed each other and psychosis, and this influenced patterns of relating.
Practitioner points
A safe therapeutic space for both client and family can help them discuss sensitive issues, restore emotional connections and reach better understandings of psychosis.
Exploring family relational experiences, attachment and attributions can be helpful in gaining understanding of how problems in psychosis are maintained.
Family intervention can help families identify helpful versus unhelpful interactions and make positive changes.
This original paper examines the underresearched area of therapist pregnancy. It explores the impact of psychosis as an additional complicating factor to the therapeutic process and the experience of one British counselling psychologist working in the National Health Service whilst pregnant. Five brief client summaries/clinical examples are presented to explore the common themes of anger, rejection, abandonment and envy that often emerge following the disclosure of a therapist’s pregnancy or the opposite reactions of over-protectiveness and an unwillingness to engage in therapy for fear of harming the therapist. Recommendations are made for further research within this neglected area and the need to incorporate the themes within training for therapists and training for supervisors.
Objectives. The aim of this study is to explore the meaning and significance of family interventions (FI) for the individual who experiences psychosis, and its significance for recovery.
Design. A qualitative in-depth interview design was used to explore individuals’ experience of FI and its meaning to them.
Methods. Seven individuals recovering from psychosis attending integrated FI sessions were interviewed using a semi-structured interview schedule developed with service user input. Interviews were recorded, transcribed verbatim, and explored using Interpretative Phenomenological Analysis.
Results. Three central themes highlighted the participants’ experience: (1) They welcomed the shared experience with their families and felt contained and valued by the therapists; (2) They felt the sessions contributed to changed patterns of relating within the family and the creation of new meaning through the validation of multiple perspectives; and (3) They described how the family sessions supported a new positioning in the world, a sense of their own empowerment and personal responsibility, greater self-acceptance, an increased ability to manage emotions, and hope for the future.
Conclusions. Conditions in the family sessions provided an environment for changes in patterns of relating, personal meaning, and emotions to take place. Recovery, for these individuals, appeared to be about repositioning themselves in the world. The shared experience of sessions and the recognition of multiple perspectives within a containing environment may be related to recovery via the development of new perspectives and a more robust sense of self. This has clinical implications for the focus of FI sessions.
Metacognition has been shown to be impaired in people diagnosed with schizophrenia, and related to poorer social functioning. To date, no research has looked at the relationship between a particularly rare – but problematic – social functioning outcome (violence) and metacognition. The present study explored patterns of metacognition in people diagnosed with schizophrenia and a history of interpersonal violence, and comparing them to a group with schizophrenia and no history of violence. Participants took part in an interview which explored stress and coping, which was subsequently coded for metacognitive ability. There were no differences between the two groups. Metacognition was significantly correlated with negative symptoms. The limitations of the study and implications for clinical practice are discussed.
With the current emphasis on evidence-based practice, the significance of the social worker–client relationship as a prerequisite
to client goal attainment has been de-emphasized. This is particularly problematic with regard to practice with psychotic
clients, with whom practitioners often have difficulty establishing therapeutic relationships. The purposes of this article
are to examine the communication deficits of persons with psychotic disorders and, with an extended example, to describe five
intervention guidelines for social workers toward the goal of developing positive working relationships with them.
KeywordsClinical social work–Psychotherapy–Psychosis–Mental illness
Signs (e.g., words, gestures, tokens, pictures) point to something besides themselves and are observable. Using signs, events can reproduce themselves (in part) across time and space. Signs change meaning each time they are used, but they also accumulate meanings from each use. Voices are active subdivisions (or collectivities) of people, internalized agents representing people, and events formed from traces of previous experience. People can Ire understood as communities of voices. Most theoretical approaches to psychotherapy recognize some forms of multivoicedness. Multiple voices may represent depth of resources and flexibility or fragmentation and dissociation, depending on the strength of the meaning bridges between the voices, which are constructed of signs. This article reviews research findings and problems that led me to my interest in signs and voices, and gives psychotherapy case examples of sign-mediated assimilation of problematic voices into the client's community of voices.
The understanding of grounded theory method is partly dependent on an awareness of the method's ontological, epistemological, and methodological perspectives; the traditional symbolic interactionist theoretical underpinnings; and the identification of the relevant paradigm of inquiry within which the method resides. An analysis of these factors suggests that grounded theory method has traditionally been sited in a postpositivist inquiry paradigm but is evolving and moving toward the constructivist inquiry paradigm. The suggestion is made that the postmodern status of the method is also evolving.
Bakhtin's (1973) polyphonic novel serves as a metaphor for a dialogical conception of the self. In line with this metaphor, it is argued that a narrative approach leads to a multivoiced conception of the self, in which the poles of a personal construct are related as opposing characters positioned in an imaginal space. In this space, the I fluctuates among positions in a dialogical fashion. Two main features of the relation between positions are discussed: intersubjective communication and dominance. These features form the basis of a theory and methodology that have led to the discovery of a particular phenomenon: dominance reversal. This phenomenon represents a radical change in the dominance relation of contrasting positions within a limited time period, in an apparent absence of causal factors. The implications of this phenomenon for the organization and reorganization of the self are discussed.
Every serious school of psychotherapy has its own theory--often only vaguely formulated--concerning the active ingredients in psychotherapy. Many of these theories are presented as mutually exclusive. The author presents an overview of some of the important, primarily psychoanalytically founded, theories of the factors in individual psychotherapy that are responsible for inducing change. It is impossible to pinpoint any single factor that is crucial in every therapy. What is needed is a nondogmatic, multiple-factor model that successfully incorporates the knowledge obtained from the many existing theories of psychotherapy-induced change. In practice, it is often difficult to maintain the traditional distinction between specific and nonspecific factors, just as it is difficult to distinguish the roles played by purely therapeutic factors--relating to the technique of the therapist--and by extratherapeutic factors. The author also addresses the epistemological status of the various claims put forward, by the many different theories of psychotherapy, concerning the active ingredients in psychotherapy. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Asks the questions: How do personal narratives disintegrate in schizophrenia, and how should narrative issues in schizophrenia be addressed in individual psychotherapy? To examine these issues, this article presents a case analysis of 19 Ss suggesting that narratives in schizophrenia are compromised when internal dialogue either dissolves into cacophonous disarray or becomes too singularly and rigidly organized. It is suggested, therefore, that one way psychotherapy may be useful to persons with schizophrenia is to facilitate the reemergence of internal dialogue through external dialogue. In particular, psychotherapy can assist persons with schizophrenia to develop a narrative that allows for recovery by creating a context for increasing self-awareness and agency. The authors propose that, in the midst of the ongoing development of numerous psychosocial treatments for schizophrenia, the ability to facilitate narrative coherence may represent a unique psychotherapeutic contribution to recovery for persons with this condition. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
ABSTRACT The story a person tells about his or her life is viewed as a polyphonic novel. This metaphor implies that the self is multivoiced; that is, there is no single “I” as an agent of self-organization but several, relatively independent “I” positions that complement and contradict each other in dialogical relationships. From this perspective the role ofimaginal figures in the organization of the self is analyzed. A theory and method are presented allowing us to study both the content and the organization of multivoiced self-narratives. The method is illustrated with two idiographic studies, where people tell their life story not only from the perspective of the familiar “I” but also from the perspective of an imaginal figure with whom they have had a long-lasting relationship. Finally, it is argued that the metaphor of a polyphonic novel is particularly useful because it allows us to decentralize the Western concept of the self.
Human interaction, including psychotherapy, is systematically responsive; therapists' and clients' behavior is influenced by emerging context, including perceptions of each other's characteristics and behavior. Feedback and mutual influence occur on a wide range of time scales, including treatment assignment, strategy, and tactics, -and even within the delivery of interventions. Consequently, research that assumes linear relations among psychotherapeutic variables may not be trustworthy. The concept of responsiveness helps show how client characteristics, therapist characteristics, and process components may be important in psychotherapy despite a lack of linear relations to outcomes. Research strategies that incorporate responsiveness include the use of evaluative measures, systems approaches, and qualitative and narrative approaches.
Qualitative analyses of 2 clients' psychotherapies (client centered and process-experiential) investigated the developmental progression from formulating a problem to achieving an understanding of it. The results elaborated one segment in the 8-stage Assimilation of Problematic Experiences Sequence (APES), through which problematic parts of a person (described as voices to emphasize their active, agentic qualities) are thought to pass during successful psychotherapy, as they become assimilated into the self (described as a community of voices). The transition between APES Stage 3 (problem statement/ clarification) and APES Stage 4 (understanding/insight) was described as a series of substages. The results highlighted the construction of meaning bridges-semiotic links by which the problematic voice could understand and be understood by voices of the community.
The term reflective function (RF) refers to the psychological processes underlying the capacity to mentalize, a concept which has been described in both the psychoanalytic (Fonagy, 1989; 1991) and cognitive psychology literatures (e.g. Morton & Frith, 1995). Reflective functioning or mentalization is the active expression of this psychological capacity intimately related to the representation of the self (Fonagy & Target, 1995; 996; Target & Fonagy, 1996). RF involves both a self-reflective and an interpersonal component that ideally provides the individual with a well-developed capacity to distinguish inner from outer reality, pretend from ‘real’ modes of functioning, intra-personal mental and emotional processes from interpersonal communications. Because of the inherently interpersonal origins to how the reflective capacity develops and expresses itself, this manual refers to reflective functioning, and no longer of reflective-self functioning (see Fonagy, Steele, Moran, Steele, & Higgitt, 1991a), as the latter term is too easily reduced to self-reflection which is only part of what is intended by the concept.
A distinction is made between metacognitive knowledge (knowing that thoughts are not necessarily always accurate) and metacognitive insight (experiencing thoughts as events in the field of awareness, rather than as direct readouts on reality). This distinction, and its relevance to preventing relapse and recurrence in depression, is examined within the Interacting Cognitive Subsystems (ICS) theoretical framework. This analysis suggests, as an alternative to cognitive therapy with its focus on changing the content of depression-related thought, the strategy of changing the configuration, or mode, within which depression-related thoughts and feelings are processed, i.e. changing one's relationship to inner experience. Specifically, facilitating a metacognitive insight mode, in which thoughts are experienced simply as events in the mind, offers an alternative preventative strategy. Mindfulness training teaches skills to enter this mode, and forms a central component of Mindfulness-based Cognitive Therapy, a novel, cost-efficient group preventative programme, for which there is encouraging evidence of effectiveness. Copyright © 1999 John Wiley & Sons, Ltd.
Personal narratives are the stories people tell to themselves and others to place daily experiences in context and make meaning of them. They connect past to future, bringing together remembered and felt experience, lending coherence and structure to the foundations of identity. In schizophrenia, however, personal narratives often appear to have lost their synthetic power. Phenomenologically speaking, how do personal narratives disintegrate in schizophrenia, and how should narrative issues in schizophrenia be addressed in individual psychotherapy? To examine these issues, this article presents a case analysis suggesting that narratives in schizophrenia are compromised when internal dialogue either dissolves into a cacophonous disarray or becomes too singularly and rigidly organized. We suggest, therefore, that one way psychotherapy may be useful to persons with schizophrenia is to facilitate the reemergence of internal dialogue through external dialogue. In particular, psychotherapy can assist persons with schizophrenia to develop a narrative that allows for recovery by creating a context for increasing self-awareness, and agency. We propose that, in the midst of the ongoing development of numerous and effective psychosocial treatments for schizophrenia, the ability to facilitate narrative coherence may represent a unique psychotherapeutic contribution to recovery for persons with this condition.
Schizophrenia is widely considered the most severe and disabling of the mental illnesses. Yet recent research has demonstrated that many people afflicted with the disorder are able to recover to a significant degree. Living Outside Mental Illness demonstrates the importance of listening to what people diagnosed with schizophrenia themselves have to say about their struggle, and shows the dramatic effect this approach can have on clinical practice and social policy. It presents an in-depth investigation, based on a phenomenological perspective, of experiences of illness and recovery as illuminated by compelling first-person descriptions. This volume forcefully makes the case for the utility of qualitative methods in improving our understanding of the reasons for the success or failure of mental health services. The research has important clinical and policy implications, and will be of key interest to those in psychology and the helping professions as well as to people in recovery and their families.
This book presents a respectful, often playful approach to serious problems, with groundbreaking theory as a backdrop. The authors start with the assumption that people experience problems when the stories of their lives, as they or others have invented them, do not sufficiently represent their lived experience. In this way narrative comes to play a central role in therapy.
There is nearly universal acceptance that persons with schizo-phrenia often experience a profound disruption in their basic sense of self. But what does this disruption in sense of self reflect? Is this the result of an internal catastrophe? If so, where and in what manner did this catastrophe occur? To address these issues this paper will review various perspectives on disruptions of self-experience in schizophrenia as well as literature regarding how sense of self among people in general normally develops out of dialogues both within the individual and between the self and others. Following this we will theorize that the subjective experience of personal incoherence in schizophrenia may reflect a collapse of the ability to maintain ongoing dialogue within the self, specifically arguing that as internal dialogues evaporate, self-experience and personal narrative can devolve into one of three forms: (a) a barren and empty self-organization; (b) internal cacophony; or (c) self constructions dominated by rigid, non-evolving monologues. Lastly, implications for treatment and recovery will be discussed, including the potential usefulness of a focus on interventions that might revitalize clients' internal and external dialogue.
Summarizes the results of macrolevel process–outcome research, drawing on the client-centered and experiential therapies (CC/ET) literature whenever possible, and the main findings of R. Sachse's (1992) microprocess research on therapist facilitation of client self-exploration, the key client microprocess, and CC/ET and related humanistic therapies. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
There are three principal sections to this book. This first section is an introduction that provides the theoretical and political frame for the material presented in the other two sections.
In this first section, I have presented an overview of some of the more recent developments in social theory that David and I have found of compelling interest, and some of what we believe to be the implications of those ideas for therapy. The discussion of theory includes some of Michel Foucault's thought on power and knowledge.
It is our hope that the material that we have included in this book adequately reflects our exploration of practices of the literate tradition in a therapy that is situated in the text analogy and in Foucault's thought, and fairly represents the experience of these practices on behalf of those persons who have sought therapy. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
the essence of . . . speech [in schizophrenics] is that the listener cannot understand what the speaker is talking about / these disorders seem to reflect lack of ideas, difficulties with planning a discourse and a tendency to perseverate on certain themes / suggests that all these signs, including incoherence of speech, reflect defects of language use rather than language competence / in other words, schizophrenic patients have problems with communication, not language / cites patients with "delusions of reference," who falsely believe that people are trying to communicate with them / discusses auditory hallucinations from the point of view of them typically involving patients hearing voices trying to influence their behavior / propose that all these abnormalities of communication arise because schizophrenic patients have difficulty in making inferences, particularly about the mental state of others (PsycINFO Database Record (c) 2012 APA, all rights reserved)
The transfer of knowledge occurs most effectively through the stories – the narratives – that we tell others and ourselves about our experiences. Cognitive behaviour therapists may incorporate stories, metaphors and analogies within their daily practice, when assessing suitability for treatment, challenging unhelpful styles of thinking, and addressing maintaining behaviours. The collaborative development of stories can enhance rapport, enable clients to gain a new perspective upon their problems, increase personal impact and clarity of meaning, and reinforce clients' motivation to effect therapeutic change. This paper discusses the use of the story, anecdote, metaphor, analogy, and quotation within cognitive behaviour therapy (CBT). The contribution of other psychotherapies to these forms of therapeutic communication is outlined. Practical examples of stories and analogies that illustrate the main principles of CBT and its application to the treatment of common mental disorders are described. The benefits and limitations of employing individualized analogies and stories within the therapy session are highlighted.
Background. A neuropsychological formulation of
schizophrenia has suggested that problems with
meta-representation underpin both positive and negative symptoms.
This study tested Frith's
account by asking patients experiencing an acute episode of psychosis
to complete a set of tasks that involved Theory of Mind (ToM) skills.
This paper describes two cases involving the use of cognitive behavioural therapy (CBT) to treat the positive symptoms of schizophrenia. In both cases the individuals were experiencing acute psychotic symptoms during their first admission to hospital. Each case illustrates how CBT was used to tackle a particular issue pertinent to the delivery of treatment at this early stage in the development of an individual's experiences of psychotic symptoms. Case one describes therapy with a young person of 17 where developmental issues are pertinent; case two describes the use of therapy to engage a person whose symptoms have ostensibly remitted. In both cases the promotion of understanding of the origin of their experiences was vital to the conduct of therapy. The implications of these issues to conducting therapy with this client group and the methods used to overcome them are discussed with reference to the future developments of cognitive behavioural therapy for use with this client group.
Assertions that changes or transformations in narratives contribute significantly to recovery from schizophrenia persist as a cornerstone of some psychotherapies. Yet when narrative transformation occurs in schizophrenia, what is there about the client's story that tangibly changes, and how might that be measured? To address this issue, we review literature on the importance of narrative transformation and identify narrative qualities that might theoretically change. We then report content and thematic analyses of the qualities of narratives that might potentially change over 14 months of psychotherapy. These analyses suggest that narratives in schizophrenia may gain complexity and dynamism, but the changes do not entail the creation of a new story or the 'awakening' of an 'old' self. From these analyses, the hypothesis that narrative transformation may occur in terms of growth in the richness of the internal dialogue that produces narrative is posed for future research.
A distinction is made between metacognitive knowledge (knowing that thoughts are not necessarily always accurate) and metacognitive insight (experiencing thoughts as events in the field of awareness, rather than as direct readouts on reality). This distinction, and its relevance to preventing relapse and recurrence in depression, is examined within the Interacting Cognitive Subsystems (ICS) theoretical framework. This analysis suggests, as an alternative to cognitive therapy with its focus on changing the content of depression-related thought, the strategy of changing the configuration, or mode, within which depression-related thoughts and feelings are processed, i.e. changing one's relationship to inner experience. Specifically, facilitating a metacognitive insight mode, in which thoughts are experienced simply as events in the mind, offers an alternative preventative strategy. Mindfulness training teaches skills to enter this mode, and forms a central component of Mindfulness-based Cognitive Therapy, a novel, cost-efficient group preventative programme, for which there is encouraging evidence of effectiveness. Copyright © 1999 John Wiley & Sons, Ltd.
A cognitive approach to the understanding of psychotic symptoms that focuses on the interpretation of intrusions into awareness is outlined. It is argued that many positive psychotic symptoms (such as hallucinations and delusions) can be conceptualized as intru-sions into awareness or culturally unacceptable interpretations of such intrusions, and that it is the interpretation of these intrusions that causes the associated distress and disability. It is also argued that the nature of these interpretations is affected by faulty self and social knowledge and that both the intrusions and their interpretations are maintained by mood, physiology, and cognitive and behavioural responses (including selective attention, safety behaviours and counterproductive control strategies). The literature is reviewed and found to be compatible with such a model and the clinical implications are discussed.
The author suggests that the use of mental models and language registers may help an analysis to proceed, especially in psychosis, when the patient has not yet developed a mental space that will allow him/her the functions of knowledge and containment of emotions. Models, according to Bion, are a primitive approach to abstraction and a manifestation of the analyst's reverie that enables him/her to transform sense data into alpha-elements. Ferrari, in a further development of Bion's theories, hypothesises a relationship between the transference and the internal level of body-mind communication, and proposes the use of language registers to sustain the psychoanalytic process. The author presents several clinical examples from a thirteen-year, four-session-a-week analysis of a psychotic analysand who was initially confused, paranoid and altogether unable to bring self-reflective thought to bear on her overwhelming emotions and had, by the end of the analysis, completely recovered from her psychotic symptoms. The clinical material shows how the technical tools of mental models and language registers helped in the construction of a mental space and spatio-temporal parameters, permitting the patient to tolerate overwhelming concrete emotions and finally to recognise and work through the emotions of an intense transference.
Problematic action patterns that patients are unable to abandon or modify are important treatment targets in cognitive analytic therapy. They are called procedural sequences in the conceptual model underlying the approach. Interpersonal events in the patients' lives, and in the consulting room as well, frequently display such patterns. They are called reciprocal role procedures. In the present paper the sequential description of problem procedures will be examined by using Bakhtin's dialogical understanding of mental phenomena. A restatement of the original concept will be presented with the aim of integrating the sequential and reciprocal aspects of problematic action patterns. The revised concept of dialogical sequences will be illustrated by a number of case vignettes. The analysis of dialogical sequences provides a clear conceptual basis for early description of problem procedures in therapy. It also provides an effective tool for a detailed supervision of therapy sessions. Finally, dialogical sequence analysis may be used as a psychotherapy process research method to examine the interpersonal patterns in patient narratives.