A. Cooke

Identifying potential predictors of traumatic reactions to psychotic episodes

OBJECTIVES The experience of a psychotic episode can sometimes lead to post-traumatic stress disorder (PTSD) symptoms. The objective of the research was to identify candidate predictors of such negative reactions for future prospective study. We examined six predictors identified from the PTSD and psychosis literatures in a retrospective study: a history of previous trauma, a history of previous episodes of psychosis, perceived helplessness and uncontrollability at the time of the index psychotic episode, the content of persecutory delusions at episode and the perceived presence of crisis support after the psychotic episode. DESIGN The design was a cross-sectional self-report and interview study of people with recently remitted symptoms of psychosis. METHOD 36 individuals with delusions and hallucinations that had remitted in the past year were assessed for the presence of PTSD symptoms in reaction to their most recent psychotic episode. Measures of the potential predictors were also taken at this point and associations with PTSD symptoms tested. RESULTS 61% of the individuals with remitted positive symptoms had a reaction to their psychotic episode that was potentially severe enough to receive a PTSD diagnosis. Higher levels of PTSD symptoms were associated with all six predictors tested. CONCLUSIONS The study provides further evidence that negative reactions to psychotic episodes are relatively common. Clinicians may wish to assess for such symptoms. The study extended these findings by identifying a number of candidate psychological predictors of PTSD reactions such as perceptions of uncontrollability and absence of support. Prospective longitudinal studies are required to test the causal significance of these factors. More broadly, the findings indicate that traumatic stress in response to intra-psychic events such as delusions can be understood in similar ways to traumatic stress arising from physical traumas such as disasters.

Developing positive relationships with voices: A preliminary grounded theory

Background: Research has been exploring the phenomenon of ‘voice hearing’ within a relational framework. To date, studies have paid limited attention to voice hearers who view the experience positively. Material: Semi-structured interviews were conducted with five mental health service users and seven non-service users who had had positive experiences of hearing voices. Interview transcripts were analyzed using Grounded Theory. Conclusions: The preliminary theory suggests that the moderation of fear and control may impact on relationships with voices. Actively engaging with voices to understand their subjective meaning may be beneficial. Promoting a positive self-concept and connecting with communities who value and accept voice-hearing experiences may be particularly important.

“But what about real mental illnesses?” Alternatives to the disease model approach to ‘schizophrenia’

The old dichotomy between “neurosis” and “psychosis” appears to be alive and well in the debate about psychiatric diagnosis. It is often suggested that while diagnostic alternatives may be appropriate for the relatively common forms of distress with which we can all identify such as anxiety and depression, psychiatric diagnoses remain vital for experiences such as hearing voices, holding beliefs that others find strange, or appearing out of touch with reality—experiences that are traditionally thought of as symptoms of psychosis. Such experiences are often assumed to be symptoms of underlying brain pathology or “real mental illnesses” that need to be diagnosed or “excluded” (in the medical sense of ruling out particular explanations of problems) before deciding on the appropriate intervention. This article argues that this belief is misguided, and that far from being essential, psychiatric diagnosis has the potential to be particularly damaging when applied to such experiences. It describes an alternative perspective outlined in a recent consensus report by the British Psychological Society Division of Clinical Psychology (Understanding Psychosis and Schizophrenia), which has attracted significant attention in the United Kingdom and internationally. The report argues that even the most severe distress and the most puzzling behavior can often be understood psychologically, and that psychological approaches to helping can be very effective. It exhorts professionals not to insist that people accept any one particular framework of understanding, for example, that their experiences are symptoms of an illness. This article outlines that report’s main findings, together with their implications for how professionals can best help.

Responses to the Publication of the American Psychiatric Association’s DSM-5:

The idea and practice of diagnosis in psychiatry has always been controversial. Controversy came to a head in the period preceding and immediately after publication of the latest version of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders–Fifth edition. There was widespread international discussion and debate not only in scholarly journals but in mainstream and social media, and to the formation of International DSM Response Committee and an International Summit on Psychiatric Diagnosis. This article documents that process and outlines the issues that provoked, and continue to provoke most controversy, from the (admittedly personal) perspective of those involved. It ends with suggestions of alternatives to diagnosis, which avoid some of these problems and outlines how these are being taken forward. The next 10 years are likely to see significant change.

Aims for service user involvement in mental health training: staying human

Purpose The purpose of this paper is to examine the impact of service user involvement in mental health training but little is known about what staff, trainees and service users themselves want to achieve. Design/methodology/approach Three separate focus groups were held with service users, training staff and trainees associated with a clinical psychology training programme. Thematic analysis was used to identify aims for involvement. Findings All groups wanted to ensure that future professionals “remained human” in the way they relate to people who use services. Service user and carer involvement was seen as a way of achieving this and mitigating the problem of “them and us thinking”. The authors found that groups had some aims in common and others that were unique. Service users highlighted the aim of achieving equality with mental health professionals as an outcome of their involvement in teaching. Research limitations/implications The samples were small and from one programme. Practical implications Common aims can be highlighted to foster collaborative working. However, the findings suggest that service users and carers, staff and trainees may also have different priorities for learning. These need to be recognised and addressed by mental health educators. Originality/value This was the first study to explore in depth the differing aims of different stakeholder groups for service user involvement. Clarification of aims is a vital first step in developing any future measure of the impact of service user involvement on mental health practice.

Changing society’s whole approach to psychosis

The British Psychological Society’s report “Understanding Psychosis and Schizophrenia: why people sometimes hear voices, believe things that others find strange, or appear out of touch with reality, and what can help” (Cooke, A. (ed.), 2014) has generated extensive media coverage and debate. It is a book-length consensus report outlining in everyday language a psychosocial approach to experiences that are commonly thought of as psychosis. Written by a group of 24 authors including many of the leading psychology researchers in the field, together with people who have themselves experienced psychosis, it aims to provide an accessible overview of the current state of knowledge in language that everyone can understand. This editorial summarises the report, the reasons we wrote it and the responses it has received.

“We could end up in a lot of trouble” Teachers’ communications with young children about mental health

Purpose – Stigma towards people with mental health problems is a significant problem and appears trenchant despite recent anti-stigma campaigns. Attitudes develop in young children, and may be stronger and less malleable in adolescence. Early intervention may be important for mental health education and stigma prevention. Theory, evidence and practical considerations all suggest that teachers’ involvement is key. By exploring communication about mental health between teachers and young children, it will be possible to elaborate how stigma develops and may be ameliorated. The purpose of this paper is to explore teachers’ accounts of this communication and the factors that influence it. Design/methodology/approach – Semi-structured interviews with 15 primary school teachers were transcribed and analysed using a grounded theory approach. Findings – Discussions about mental health were largely absent from the classroom, due to teachers’ anxiety. Teachers felt the need to protect children from exposure to peop...

Identity and Cause of Problems: The Perceptions of Patients with a Diagnosis of Schizophrenia

This study explored the beliefs held by 17 individuals with a diagnosis of schizophrenia on the identity and cause of their problems using a semi-structured interview. Just over half of the sample considered their main difficulty to be something other than a psychiatric or psychological problem. Nevertheless, all participants reported having at least one problem, and a range of views concerning the causes of these problems were elicited, with an average of five causal factors endorsed. This suggests that traditional insight scales fail to capture the complex subjective models of understanding held by individuals with a diagnosis of schizophrenia.

“It doesn’t mean I’m useless”: how do young people experiencing psychosis contribute to their families and why are contributions sometimes overlooked?

Abstract Purpose: Psychosis is often seen as a “burden” on families and affected individuals frequently hold a negative view of themselves. This study explored the ways in which young adults who have experienced first-episode psychosis make a positive contribution within their families. Methods: Fifteen participants (seven young people with experience of psychosis and eight relatives) were interviewed separately. Their accounts were analysed using grounded theory methodology. Results: For many individuals, their experience had led to a catastrophic redefinition of their identity. However, they continued to contribute significantly both within their families and within their wider communities. The redefinition of identity sometimes appeared to create a “perceptual filter” whereby both the person themselves and family members overlooked or minimised their contribution, focusing instead on being alert to signs of psychosis or illness. Conclusions: Shame and a focus on symptoms rather than achievements and contributions can significantly limit opportunities, expectations and movement beyond an illness identity. It is important for clinicians to be aware of this and to help young people and their families to notice and value positive contribution, and so promote recovery, well-being and post-traumatic growth.

Diagnostic cultures: A cultural approach to the pathologisation of modern life

I got some funny looks when reading this book. I was on holiday at the time in the Greek islands, sitting by the Aegean, and should probably have been reading Joanna Trollope. Surprisingly, though,...