STAYING WELL AFTER PSYCHOSIS

Transcription

1 STAYING WELL AFTER PSYCHOSIS ACognitive Interpersonal Approach to Recovery and Relapse Prevention Andrew Gumley University of Glasgow and Matthias Schwannauer University of Edinburgh

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3 STAYING WELL AFTER PSYCHOSIS

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5 STAYING WELL AFTER PSYCHOSIS ACognitive Interpersonal Approach to Recovery and Relapse Prevention Andrew Gumley University of Glasgow and Matthias Schwannauer University of Edinburgh

6 Copyright 2006 John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex PO19 8SQ, England Telephone (+44) (for orders and customer service enquiries): Visit our Home Page on All Rights Reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning or otherwise, except under the terms of the Copyright, Designs and Patents Act 1988 or under the terms of a licence issued by the Copyright Licensing Agency Ltd, 90 Tottenham Court Road, London W1T 4LP, UK, without the permission in writing of the Publisher. Requests to the Publisher should be addressed to the Permissions Department, John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex PO19 8SQ, England, or ed to permreq@wiley.co.uk, or faxed to (+44) Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The Publisher is not associated with any product or vendor mentioned in this book. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold on the understanding that the Publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought. Other Wiley Editorial Offices John Wiley & Sons Inc., 111 River Street, Hoboken, NJ 07030, USA Jossey-Bass, 989 Market Street, San Francisco, CA , USA Wiley-VCH Verlag GmbH, Boschstr. 12, D Weinheim, Germany John Wiley & Sons Australia Ltd, 42 McDougall Street, Milton, Queensland 4064, Australia John Wiley & Sons (Asia) Pte Ltd, 2 Clementi Loop #02-01, Jin Xing Distripark, Singapore John Wiley & Sons Canada Ltd, 22 Worcester Road, Etobicoke, Ontario, Canada M9W 1L1 Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books. Library of Congress Cataloging-in-Publication Data Gumley, Andrew. Staying well after psychosis : a cognitive interpersonal approach to recovery and relapse prevention / Andrew Gumley, Matthias Schwannauer. p. cm. Includes bibliographical references and index. ISBN-13: (hbk) (pbk) ISBN-10: (hbk) (pbk) 1. Schizophrenia Treatment. 2. Schizophrenia Relapse. 3. Psychotherapy. 4. Cognitive therapy. I. Schwannauer, Matthias. II. Title. [DNLM: 1. Psychotic Disorders therapy. 2. Psychotic Disorders prevention & control. 3. Recurrence prevention & control. 4. Cognitive Therapy methods. WM 600 G974s 2006] RC514.G dc British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library ISBN (hbk) (pbk) ISBN (hbk) (pbk) Typeset in 10/12pt Palatino by SNP Best-set Typesetter Ltd., Hong Kong Printed and bound in Great Britain by TJ International Ltd, Padstow, Cornwall This book is printed on acid-free paper responsibly manufactured from sustainable forestry in which at least two trees are planted for each one used for paper production.

7 CONTENTS About the Authors Preface Foreword by Max Birchwood Acknowledgements ix xi xv xvii PART I THEORETICAL OVERVIEW Current Perspectives on Relapse, Relapse Detection and Prevention Introduction Psychological Therapies and Relapse Prevention Affect, Meaning and Relapse A Cognitive Behavioural Model of Early Signs and Relapse.. 23 Antipsychotic Medication and Relapse Implications for Staying Well after Psychosis Attachment Theory, Self-regulation and Psychosis Introduction Patterns of Attachment Attachment Theory and Later Psychopathology Stability of Attachment Organisation Attachment Organisation and Psychosis Psychological Factors in Vulnerability and Transition to Relapse Introduction The Interpersonal Context The Wider Social Context of Psychosis Significant Life Events Trauma Interpersonal Coping

8 vi CONTENTS Appraisals of Psychosis and Emotional Distress Conclusions PART II OVERVIEW OF STRUCTURE, STYLE AND ORGANISATION OF THERAPY Overview of Principles and Procedures Introduction Primary and Secondary Outcomes Assessment Structure of Therapy Style of Therapy Basic Elements of the Therapeutic Stance General Outline of Therapy Sessions Service Model Strategies for Engagement and Formulation Introduction Attachment Organisation, Recovery and Distress Validation The Evolution of Therapeutic Discourse Case Formulation Case Formulation in SWAP Conclusions PART III SPECIFIC COGNITIVE AND INTERPERSONAL STRATEGIES FOR RECOVERY AND RELAPSE PREVENTION AFTER PSYCHOSIS Reorganisation of the Self in Recovery: Working with Humiliation, Entrapment and Loss Introduction Life Events and their Dimensions Bowlby on Loss Clinical Interventions and Techniques Conclusions Working with Interpersonal Distrust: Developing a Conceptualisation of the Paranoid Mind Introduction Paranoia as an Interpersonal Threat Response The Paranoid Mind is Strategically Deployed

9 CONTENTS vii Attachment and Paranoia Problems with the Term Paranoia Working with the Personal Distress of the Paranoid Mind Awareness of the Paranoid Mind Development of an Accepting Rationale for Paranoia as a Response Benefits and Costs of the Paranoid Mind Development of Alternative Interpersonal Strategies Conclusions Working with Traumatic Reactions to Psychotic Experiences Introduction Psychosis as a Traumatic Event Trauma Theory Assimilation and Accommodation Exploring Traumatic Reactions Explaining Traumatic Reactions Exploring Meaning within Traumatic Memories and Imagery. 154 Contrasting Experiences of Psychosis and PTSD Conclusions Interpersonal Strategies Introduction The Social Environment Interpersonal Environments as a Basis for Psychological Intervention The Role of Interpersonal Anxieties and Social Withdrawal Areas of Interpersonal Difficulties Working with Interpersonal Sensitivity Conclusions Working with Underlying Schemata and Core Beliefs Introduction Early Parental Loss and Psychopathology Childhood Abuse and Neglect Psychological Sequelae of Childhood Abuse and Neglect Unresolved Attachment Status Early Childhood Trauma and Psychosis Trauma, Dissociation and Schizotypy Schemata and Internal Working Models Identifying Schemata Schemata and Behaviour Relationships Core Belief Change Strategies in Cognitive Therapy

10 viii CONTENTS Working with Underdeveloped Strategies Conclusions Awareness, Intrusiveness and Fear of Relapse Introduction Phenomenology of Relapse Subjective Experiences and Psychosis Appraisals and Relapse Awareness, Intrusiveness and Fear Cognitive Behavioural Therapy (CBT) and Relapse Prevention Exploring Experiences of Relapse Explaining Beliefs Early Signs Monitoring The Initial Interview for Targeted CBT Testing the Formulation Decatastrophising Relapse Contracting Intervention Subsequent Sessions Introducing Flexibility into Beliefs Transforming Beliefs Testing Transformed Beliefs Conclusions Conclusion Introduction Overview of the Treatment Manual Therapist Training Therapeutic Context Appendix I Fear of Recurrence Scale (FoRSe) Questionnaire Appendix II Diagrammatical Formulation of Early Signs Bibliography Index

11 ABOUT THE AUTHORS 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 severe 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 the 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 interests include the relationship between interpersonal and cognitive factors in developmental models of severe and enduring disorder groups. He is particularly interested in the developmental onset of severe 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

12 x ABOUT THE AUTHORS 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.

13 PREFACE When writing this book we made a number of decisions about the language used to refer to individuals who have had distressing psychotic experiences. We do not refer to diagnostic entities such as schizophrenia. We consider psychosis as an integrative and collective term used to describe a range of human experiences, such as hearing voices or suffering from persecutory paranoid beliefs. In addition, we wanted to use small case vignettes and patient therapist narratives to illustrate therapeutic processes. In doing so, we have had to consider a range of our own clinical and supervision experiences when creating characterisations of therapy issues. We have given our characterisations of typical and recurring therapeutic issues names so that readers can follow the progress of therapeutic scenarios. These named characterisations do not portray individual clients. In the past 15 years there has been a revolution in our understanding of psychotic experiences. This revolution is linked to the emerging acceptance of psychological models of psychosis, the growing importance and centrality of user involvement, and the evolution of an empirical evidence base, which attests to the effectiveness of cognitive behavioural therapies for psychosis. However, so far the evidence that individual psychological interventions such as CBT are effective in preventing recurrence of further distressing psychotic episodes is lacking. This is in contrast to family-based interventions, which have demonstrated significant and important effects on reducing the likelihood of recurrence of psychosis and readmission to hospital. However, the uptake and provision of family interventions in the UK and elsewhere have been limited and many families do not find these very accessible. In addition, many people who have experienced psychosis do not necessarily live with their families, and may be living alone and be socially isolated but also their perceived key problems may not be situated within a family context or relationships. This is a group who are also at an elevated risk of recurrence. Furthermore, the impact of recurrence of psychosis can be devastating for individuals themselves, their loved ones and their family. Psychosis can also have long-term effects on individuals lifespan development, particularly in terms of the individual s social and vocational development, which is often significantly compromised by the sequelae of the onset of a

14 xii PREFACE first episode in late adolescence. For example, individuals often experience personal trauma associated with the psychosis itself or the experience of hospitalisation; there is often a loss of expectations and hopes for the future, impaired secondary individuation and personal independence, increased disengagement of friends and family, and significant levels of stigma and socio-economic discrimination. Repeated recurrence of psychosis brings about additional losses, re-traumatisation, more pervasive and distressing psychotic experiences, and greater social disabilities. Therefore, we feel that there is an urgent need to develop an individually based psychological therapy aimed at the prevention of relapse. In attempting to do so, we describe an integrative cognitive interpersonal approach to support individuals who are recovering from psychosis. A framework of psychological treatment is presented here that incorporates various treatment strategies, which are designed to facilitate emotional recovery from psychosis, the prevention of psychosis recurrence and to optimise interpersonal and social development. This book is based on the premise that psychosis is fundamentally a normal human experience, the form and content of which reflect core cognitive, interpersonal and developmental life tasks and experiences. This book has been structured in such a way that those interested in the wide-ranging theoretical and empirical evidence that we have drawn upon for our therapeutic approach should read Chapters 1, 2 and 3. Part II provides an overview of the structure, style and organisation of therapy. Specifically, Chapter 4 deals with issues of therapeutic structure and style, while Chapter 5 provides a closer view of our approach to the process of engagement and formulation. Throughout the first five chapters we make frequent reference to attachment theory. This is a major theme of this book and our approach to staying well after psychosis. There are numerous theoretical and empirical reasons for this and we would direct readers attention to Chapters 2 and 3 for a detailed exposition. However, we see the rationale for this as rather straightforward. Asking people with psychosis to seek help in the context of emotional distress and during a period of heightened risk of relapse is a highly complex and demanding task. For many people, being asked to monitor their early signs and activate a prearranged action plan is challenging. Consider how difficult it is for an anxious patient to maintain the belief that his palpitations are normal in the midst of a panic attack! Attachment theory provides a developmental understanding of clients experiences of seeking help or proximity seeking in the context of distress and suffering. Attachment theory also helps us reflect on our own responses, either individually or as a service to clients attempts to seek support. Hence we can understand staying well in the context of this reciprocal interpersonal process. This theoretical stance has helped us operationalise what we try to achieve as caregivers in

15 PREFACE xiii providing a sympathetic, accepting, empathic, non-judgemental, caring and sensitive approach to providing psychological therapy in response to recovery and relapse prevention after psychosis. In writing this book, we have attempted to avoid being prescriptive. It does not necessarily follow that the flow of treatment should reflect the flow of chapters in Part III of the book. Part III details the specific cognitive and interpersonal strategies that we have found useful and which have their basis in our clinical experiences and our research experience (see Gumley et al., 2003). We have organised Part III to reflect commonly recurring issues in recovery and relapse prevention. This includes interventions to support emotional and self-reorganisation following psychosis (Chapter 6), strategies aimed at addressing interpersonal distrust and suspicion (Chapter 7), strategies aimed at alleviating the traumatic effects of psychosis (Chapter 8), interpersonal interventions aimed at supporting individuals negotiating the multiple demands of their social and interpersonal context (Chapter 9), schema-focused strategies (Chapter 10) and working with fear of recurrence of psychosis (Chapter 11). We hope that readers will access specific chapters based on their clients specific problem lists and goals, and use chapters to cross-refer to recurring themes developed within the book. We hope that Chapter 12 will support readers in this task. In discussing the recurring themes developed in this book, we have relied heavily on the work of attachment theorists, including Mary Main, Peter Fonagy and Mary Dozier. We have also taken the view that psychosis is a severe life event, which leads to the development of associated emotional distress. Understanding emotional distress following psychosis requires an understanding of the process of emotional adaptation to psychosis. For this we have relied heavily on the work of Max Birchwood, Tirril Harris and George Brown. We hope that this treatment manual will be useful to therapists who conduct family interventions for carers and loved ones of those suffering from psychosis. In writing this manual we have been greatly influenced by the work of Christine Barrowclough. Finally, in the process of attuning cognitive and interpersonal therapeutic strategies in an attachment context, we would like to acknowledge the work of Paul Gilbert, who has influenced and will continue to profoundly influence our thinking as therapists, clinical psychologists and researchers. The approaches and techniques described in this book are governed by two further principles. These are that interventions must be developmentally tailored and that the expression of psychotic experiences is understood as an adaptive and meaningful response to personal life experiences. Psychosis disrupts important developmental processes, thus skewing or stalling personal life trajectories. At the same time, psychosis appears to arise in a particular developmental context leading us to suggest that specific devel-