Staying Well After Psychosis

Andrew Gumley is Senior Lecturer in Clinical Psychology on the University of Glasgow Doctorate in clinical Psychology training Programme, a practising clinician as Honorary Consultant Clinical Psychologist in ESTEEM, North Glasgow Early Intervention Service, a trainer in cognitive behavioural psychotherapy at the Glasgow Institute for Psychosocial Interventions (GIPSI) and external consultant to the State Hospital at Carstairs Psychosocial Interventions Programme. His research interests include the evaluation of cognitive behavioural therapies for individuals who are considered to have seer and enduring mental health problems. In recent years, he has contributed to a number of randomised controlled trials of cognitive therapy involving individuals who have had or are recovering from distressing psychotic experiences, and individuals who have been diagnosed with borderline and antisocial personality disorders. His primary clinical and research interests focus on developing a psychological understanding of individual vulnerability and transition to he recurrence of psychosis. In this context Andrew is particularly interested in how the interplay between the experiences of psychosis and cognitive and interpersonal factors may prevent detection of at-risk mental states for relapse, contribute to affect dysregulation during relapse, or result in persistent and distressing emotional states such as fear of recurrence. These clinical and research interests are directed towards the development, refinement and evaluation of psychological therapies for recovery and staying well after psychosis. Matthias Schwannauer is Lecturer and Research Supervisor in  Child and Adolescent Clinical Psychology on the University of Edinburgh Clinical Psychology Training Course, Research Co-ordinator in the Young People's Unit in Edinburgh and Practising clinician as consultant clinical Psychologist in an adolescent onset psychosis service in Lothian. His current clinical and research interest include the relationship between interpersonal and cognitive factors in developmental models of server and enduring disorder groups. He is particularly interested in the developmental onset of sever mental health problems with regard to psychological factors of vulnerability and resilience to psychiatric disorders. In the past few years Matthias has investigated developmental models of interpersonal and cognitive aspects of emotion regulation in a number of populations, such as depression in a highly vulnerable group of single, young homeless adolescents with an early onset psychosis and individuals suffering from bipolar disorder. He is interested in the advancement of a developmental psychopathology model of affect regulation in a range of populations with severe and recurring psychological difficulties.

About the Authors ix

Preface xi

Foreword by Max Birchwood  xv

Acknowledgements xvii

PART I THEORETICAL OVERVIEW 1

1 Current Perspectives on Relapse, Relapse Detection and Prevention 3

Introduction 3

Psychological Therapies and Relapse Prevention 4

Affect, Meaning and Relapse 18

A Cognitive Behavioural Model of Early Signs and Relapse 23

Antipsychotic Medication and Relapse 27

Implications for Staying Well after Psychosis 32

2 Attachment Theory, Self-regulation and Psychosis 34

Introduction 34

Patterns of Attachment 36

Attachment Theory and Later Psychopathology 38

Stability of Attachment Organisation 42

Attachment Organisation and Psychosis 43

3 Psychological Factors in Vulnerability and Transition to Relapse 47

Introduction 47

The Interpersonal Context 48

The Wider Social Context of Psychosis 54

Significant Life Events 56

Trauma 57

Interpersonal Coping 59

Appraisals of Psychosis and Emotional Distress 62

Conclusions 63

PART II OVERVIEW OF STRUCTURE, STYLE AND ORGANISATION OF THERAPY 65

4 Overview of Principles and Procedures 67

Introduction 67

Primary and Secondary Outcomes 67

Assessment 68

Structure of Therapy 73

Style of Therapy 75

Basic Elements of the Therapeutic Stance 79

General Outline of Therapy Sessions 79

Service Model 84

5 Strategies for Engagement and Formulation 86

Introduction 86

Attachment Organisation, Recovery and Distress 86

Validation 91

The Evolution of Therapeutic Discourse 95

Case Formulation 97

Case Formulation in SWAP 99

Conclusions 102

PART III SPECIFIC COGNITIVE AND INTERPERSONAL STRATEGIES FOR RECOVERY AND RELAPSE PREVENTION AFTER PSYCHOSIS 103

6 Reorganisation of the Self in Recovery: Working with Humiliation, Entrapment and Loss 105

Introduction 105

Life Events and their Dimensions 106

Bowlby on Loss 109

Clinical Interventions and Techniques 111

Conclusions 122

7 Working with Interpersonal Distrust: Developing a Conceptualisation of the Paranoid Mind 124

Introduction 124

Paranoia as an Interpersonal Threat Response 124

The Paranoid Mind is Strategically Deployed 126

Attachment and Paranoia 126

Problems with the Term ‘Paranoia’ 128

Working with the Personal Distress of the Paranoid Mind 129

Awareness of the Paranoid Mind 132

Development of an Accepting Rationale for Paranoia as a Response 133

Benefits and Costs of the Paranoid Mind 135

Development of Alternative Interpersonal Strategies 137

Conclusions 138

8 Working with Traumatic Reactions to Psychotic Experiences 140

Introduction 140

Psychosis as a Traumatic Event 141

Trauma Theory 144

Assimilation and Accommodation 147

Exploring Traumatic Reactions 150

Explaining Traumatic Reactions 152

Exploring Meaning within Traumatic Memories and Imagery 154

Contrasting Experiences of Psychosis and PTSD 158

Conclusions 160

9 Interpersonal Strategies 161

Introduction 161

The Social Environment 161

Interpersonal Environments as a Basis for Psychological Intervention 165

The Role of Interpersonal Anxieties and Social Withdrawal 167

Areas of Interpersonal Difficulties 173

Working with Interpersonal Sensitivity 177

Conclusions 181

10 Working with Underlying Schemata and Core Beliefs 182

Introduction 182

Early Parental Loss and Psychopathology 182

Childhood Abuse and Neglect 183

Psychological Sequelae of Childhood Abuse and Neglect 183

Unresolved Attachment Status 185

Early Childhood Trauma and Psychosis 186

Trauma, Dissociation and Schizotypy 187

Schemata and Internal Working Models 189

Identifying Schemata 192

Schemata and Behaviour Relationships 193

Core Belief Change Strategies in Cognitive Therapy 195

Working with Underdeveloped Strategies 196

Conclusions 201

11 Awareness, Intrusiveness and Fear of Relapse 202

Introduction 202

Phenomenology of Relapse 202

Subjective Experiences and Psychosis 203

Appraisals and Relapse 205

Awareness, Intrusiveness and Fear 206

Cognitive Behavioural Therapy (CBT) and Relapse Prevention 209

Exploring Experiences of Relapse 210

Explaining Beliefs 212

Early Signs Monitoring 213

The Initial Interview for Targeted CBT 214

Testing the Formulation 215

Decatastrophising Relapse 215

Contracting Intervention 216

Subsequent Sessions 216

Introducing Flexibility into Beliefs 218

Transforming Beliefs 219

Testing Transformed Beliefs 221

Conclusions 222

12 Conclusion 224

Introduction 224

Overview of the Treatment Manual 224

Therapist Training 229

Therapeutic Context 229

Appendix I Fear of Recurrence Scale (FoRSe) Questionnaire 231

Appendix II Diagrammatical Formulation of Early Signs 233

Bibliography 235

Index 283