Recovering from Psychosis

Empirical Evidence and Lived Experience

Stephen Williams

• Publisher: Routledge
• Year: 2015
• eBook ISBN: 9781135045746
• Topic: Psychology
• Subtopic: Abnormal Psychology
• Index: Psychology

The use of first-hand service user accounts of mental illness is still limited in the professional literature available. This is, however, beginning to change, with a new 'recovery' focus in mental health services meaning that the voices of service users are finally being heard. Recovering from Psychosis: Empirical Evidence and Lived Experience synthesises a narrative approach alongside an evidence-based review of current treatment by including Stephen Williams' own personal experience as it relates to psychosis, recovery and treatment. A mental health professional himself, the author's account of his own recovery from severe mental health difficulties, without sustained intervention, challenges the orthodoxy of representation of service users in mental health.

Recovering from Psychosis critically explores and reviews the current state of the art of research and knowledge about the nature and treatment of psychosis. Working simultaneously from empirical, lived experience and philosophical perspectives, Stephen Williams:

Evaluates political and power related issues in professional understanding, knowledge-creation and treatment of people with psychosis;

Introduces the current 'recovery movement', unpacking its origins and implications for the future development of 'recovery oriented services';

Reviews, summarizes and critiques the current state of 'recovery' research, looking at the advantages and disadvantages of such an approach, examining how this is influencing the transformation of UK mental health services;

Analyses the difficulties in organisational implementation of recovery approaches, summarises the most empirically robust approaches to practice, personal and service delivery measurement;

Reviews current 'models' of psychosis and how various professional scientific groups explain the experience and nature of psychosis;

Uses lived-experience accounts taken from the scientific literature, portraying the nature of such experiences and analysing them in the face of contemporary psychological models.

Recovering from Psychosis is an essential comprehensive guide for mental health professionals, psychologists, social workers and carers, who are working with people with severe and enduring mental health difficulties diagnosed as psychosis. It addresses the practical implications of working with such difficult conditions and serves as a hopeful story of recovery for service users.

Chapter 1

The aims and intentions of recovering from psychosis

Empirical evidence and lived experience

The overarching aim of this book is to critically review the state of empirical evidence that explores the nature of recovery in relation to psychosis. A reflective semi-autobiographical commentary on the empirical evidence forms a critical ‘lived experience’ perspective. This book is primarily intended for mental health nurses but should also be of interest to other mental health professionals, regardless of their specific professional orientation, who have an interest in the development of mental health care in the light of the emerging ‘recovery’ approach. This chapter also provides a chapter-by-chapter guide of the topics addressed and the kinds of critique used and sources of information explored.

Chapter 2, ‘Introduction to Psychosis, Recovery, Post-Modernity and Trans-Modernity’, provides an introduction to the principal topic areas of psychosis and recovery. It explores the particular challenges of defining psychosis in the context of the philosophy of science. It also provides a lived experience account that is developed in subsequent chapters. This ‘autoethnographic’ approach serves to add colour through the author’s personal testimony of his lived experience. The lived experience sections, provided in shaded text boxes, act, in a sense, as case examples of the particular aspects of psychosis and recovery being explored as the book unfolds. At times, they are examined by the author in the context of the various explanatory models that are used in psychiatry and psychology in particular. Examples are also provided from the author’s clinical experience with the application of interventions and models that are under empirical scrutiny. For example, a first-hand account of using cognitive-behavioural therapy for unusual beliefs is explored in Chapter 4.

The chapter goes on to explore the rise and meaning of ‘recovery’ as applied to mental health services, and this is similarly explored from a lived experience perspective. Recovery is critically reflected upon; the potential benefits are raised but also the risks, particularly as they pertain to the development of mental health nursing. The chapter concludes by introducing the philosophical critical stances of post-modernism and trans-modernism as they apply to mental health practice.

Chapter 3, ‘An Autoethnographic Account of Psychosis in the Context of Neurobiological, Cognitive Psychological and Meta-Synthetic Analysis’, is in many regards a pivotal gateway chapter that informs the entire book. It begins with my lived experience account of developing psychosis and attempts to synthesize into this pertinent aspects of the empirical evidence. The increasingly recognized role of trauma is reviewed that has placed new emphasis on the psychosocial aspects of psychosis within what has previously been a more biologically emphasized aetiology. Relevant aspects of neurobiological, psychological, neurocognitive, neuro-computational theory and research into the genetics of psychosis are reviewed and explored, and where possible this is related to the lived experience perspective. The chapter overall intends to present both the personal perspective and an overview of current scientific models of psychosis across a range of disciplines that inform mental health care.

Chapter 4, ‘A Review of Current UK Treatment Approaches to Psychosis: Surveying Contemporary Interventions and Their Empirical Status’, seeks to provide a review of the empirical status of the mainstay of treatment interventions for psychosis. It explores the different kinds of psychological interventions being developed and used. Interventions developed from the neurocognitive theories of psychosis are evaluated, as are the rise of third-wave ‘contextual’ cognitive psychological interventions (Grant et al., 2010; Hayes, 2004) – e.g. Acceptance and Commitment and Mindfulness. A first-hand clinical experience account of delivering cognitive-behavioural therapy for psychosis is given, along with a review of the empirical evidence. The chapter concludes with a review of the empirical evidence underpinning the use of antipsychotic medication, and this is presented alongside a lived experience account of the use of medication.

Chapter 5, ‘Research into Recovery from Psychosis: An Empirical Review and Critical Reflection’, provides an overview of the current state of recovery research. It critically reflects on the rise of recovery research and the disjunction that also exists in its application to practice. Key pieces of research are discussed in detail: the development of the CHIME conceptual framework (Leamy et al., 2011), coping strategies derived from qualitative research (Phillips et al., 2009) and a review of guidance for recovery-oriented practice (Le Boutillier et al., 2011). The components of recovery-oriented practice are also reviewed in the light of emerging research (Slade et al., 2011), including supporting goal striving (Clarke et al., 2009), evidence-based coaching (Grant and Cavanagh, 2007) and the principles of a collaborative recovery model (Oades et al., 2009). The state of evidence for the rise of recovery colleges is also reviewed, and the challenges to mental health practices and research are explored in the context of this new ‘paradigm’.

Chapter 6, ‘Recovery, Psychosis and Identity’, explores the important role that identity has in the experience of psychosis and subsequent recovery. Current psychosocial understanding of the nature of identity is explored in detail, and this is linked to previous qualitative evidence on the nature of psychosis (McCarthy-Jones et al., 2013). The interplay between experiences of psychosis and psychological models is explored in relation to the impact the condition can have on a person’s identity and security of self in particular. This leads to some discussion of how current psychological interventions can attend and support the reforging of the self. An overview of narrative theory as a strand of psychological approach is reviewed and placed in the context of identity and psychosis. The wider implications of social role and stigma are addressed and this is illustrated with my lived experience account of recovery. The chapter ends with a discussion of how the organizational context of mental health services creates certain barriers to recovery.

Chapter 7, ‘Political Dimensions of Recovery’, builds on organizational issues to reflect critically in increased depth on some of the obstacles that mental health services face in adopting a transformative recovery-oriented approach. It addresses the difficulties of implementing recovery and the particular challenges of legal frameworks such as the Community Treatment Order (Burns and Molodynski, 2014). It also addresses certain professional misapprehensions about recovery and what organizations must tackle to develop a partnership approach to service delivery. Current political issues are used to highlight the real dangers for the potential abuse of the recovery approach.

Chapter 8, ‘Measuring Recovery: The Tyranny of Psychometry’, addresses the inevitable need of statutory services to measure and produce evidence of the impact of recovery-oriented practices. A post-modernist critical appraisal is made of the assumptions inherent in the application of measurements practices. A brief empirical review and critique are then given of the state of research measures of service recovery orientation and measures of personal recovery. The chapter goes on to explore what recovery measures might be capturing and how this does or does not fit with espoused recovery values – i.e. of narrative recovery and ‘re-authoring’.

Chapter 9, ‘Beyond Recovery: Towards Mental Health as Well-Being’, seeks to signpost where the development of recovery-oriented services seems to be heading. It charts the rise and promise of positive psychology and places these ideas into the wider context of health and illness. A brief review of the empirical status of positive psychological interventions is then given, and a specific example of interventions that seek to integrate a well-being- and resilience-focused approach into practice is outlined. Some of the emerging resistance and difficulties with a well-being-oriented approach are discussed, and the role of digital communities is addressed as a new frontier of mental health practice.

Chapter 10, ‘Reflections upon Recovery: The Person Is Political’, seeks to synthesize the main themes and issues covered in the preceding nine chapters. It highlights the risks inherent in the translation by research and academia of recovery into the realities of service users’ lives and clinical practice. It emphasizes the need for valuing storytelling on a variety of levels and reflects on the pitfalls and limitations of current treatment approaches. It takes stock of the state of recovery research and what it has to say about the role of identity, growth and well-being as fundamental topics of concern for mental health clinical practice.

The overarching aim of this volume is to provide a robust empirical review of the state of evidence surrounding the principal topics of recovery and psychosis. It also seeks to raise the profile of qualitative and lived experience accounts of these subjects. In addition, it seeks to critically reflect upon the status of empirical research and the inherent assumptions that are made in their undertaking. You will find that the portions of the book containing lived experience accounts (in shaded text boxes) are presented in the context of the critical review of the empirical research that they speak to.

Chapter 2

Introduction to psychosis, recovery, post-modernity and trans-modernity

This chapter introduces the principal topic areas of psychosis, recovery and post-modernity. It provides definitions of these terms and explores some of the relevant contextual issues. Recovery and psychosis are introduced from a critical evidence-based standpoint, from a post-modernist and at times a trans-modern perspective and from a lived experience first-person perspective.

The challenge of defining psychosis

The World Health Organization (WHO) and Royal College of Psychiatrists (RCP) both recognize that psychosis is a component of so-called severe mental illness (SMI), although there is little consensus over what this specifically means (Ruggeri et al., 2000). The RCP identify that losing contact with reality is a defining feature of psychosis (RCP, 2012), whereas the WHO (1992) states that it “indicates the presence of hallucinations, delusions, or a limited number of severe abnormalities of behaviour, such as gross excitement and overactivity, marked psychomotor retardation, and catatonic behaviour” (p. 10).

Ruggeri et al. (2000) operationalize this definition of SMI: “a patient has severe mental illness when he or she has the following: a diagnosis of any non-organic psychosis; a duration of treatment of two years or more; dysfunction, as measured by the Global Assessment of Functioning (GAF) scale” (American Psychiatric Association, 1987; cited in Ruggeri et al., 2000, p. 149). In these definitions, experiences of psychosis that are associated with a specific organic cause (e.g. as in the dementias or acquired brain injury) are differentiated from so-called functional psychoses where no apparent structural or physical causal precipitant can be identified. In this narrow sense, a functional psychosis is construed as a necessary constituent of SMI. This doesn’t get us much closer to understanding what psychosis is like, however, or what it is, and it presents a clearly circular argument. In this account, psychosis is a kind of SMI, and an SMI is, by this definition, one that includes a sufficient degree and kind of psychosis.

This tautology exposes a long-recognized fundamental flaw in the attempts to develop psychiatry as a scientific discipline. Science carves up the domains of study into kinds and theorizes about them (Quine, 1969). It has been keenly debated, particularly in the last 40 years of metaphysics and philosophy, as to whether special sciences such as psychology and psychiatry satisfy the conditions for ‘natural-kindhood’ (see Fodor, 1974; Dupre, 1993). Special sciences are all those that are presumed to be reducible to physics (Fodor, 1974). A fundamental question posed by the philosophy of science is whether the kinds classified by psychiatry are scientifically real. By this, they mean do they correspond to real kinds in nature?

The emergence of a substrain of medicine and psychiatry that proclaims itself to be ‘values-based’ is one of the reactions to the developing understanding that conceptualizing elements of the human condition as mental illness is not successfully “carving nature at its joints” (Slade, 2009, p. 18). A values-oriented approach directs us to consider diagnosis as a way of understanding and talking about things rather than as an explanation per se. Consider the difference in saying to a person, ‘You have a psychosis’, as opposed to, ‘Your experiences can be understood as psychosis’. The former statement implies that psychosis is a real thing to be had and proclaims the diagnosis as scientifically (and thus ontologically) valid rather than a vehicle to promote communication/understanding. These are radically different stances on the causal validity of diagnosis.

So psychosis is perhaps more helpfully viewed as a construction of psychiatry. This is not to be mistaken for invalidating the reality of the emotional distress of such diagnoses. It is instead an acknowledgement that this is simply a means of taxonomizing and individuating people who meet certain categorical criteria at a certain point in time. It provides a means of identifying them as belonging to a certain group. A ‘strong’ post-modernist argument is that it serves to create and perpetuate that group. It does little, however, to represent the rich variety of people and their experiences (of psychosis) that make them different from others who are given that label and indeed from others who are not.

A lived experience perspective of what psychosis means

My own experience of psychosis was that the nature of my thinking was such that at times it changed my experience of reality. So I present an alternative hypothesis, by virtue of lived experience: psychosis is where the process of interpreting events (both internal and external) is so catastrophically disrupted that the lens of personally held meaning alters the very experience of reality for the individual. Psychosis is thus characterized as a form of perceptual distress, a significant change in the qualitative aspects of cognitive processing that gives rise to an altered experience of reality. This approach also incorporates an explicit acknowledgement of the metacognitive nature of the experience.

This cognitive model is in some respects anchored in empirical evidence inasmuch as there is a range of cognitive psychological research that demonstrates that individuals with a diagnosis of psychosis exhibit a number of identifiable differences in the nature of their thinking (Frith, 1992; Garety and Freeman, 1999; Broome et al., 2007). I would argue that the definition of psychosis provided by the RCP is misleading in that it fails to draw upon the distinction that our experience of reality is individually and socially constructed (Berger and Luckmann, 1966). The contribution of social and personal construction to our experience of reality is evident empirically in a diverse range of social science disciplines and particularly in cognitive science.

What is recovery?

The idea of recovery is no less fraught with controversy than the understanding of what the person is endeavouring to recover from (or in relation to). In the last 20 years, the UK has seen a rise in the idea of recovery as an emerging alternative paradigm for understanding mental illness. Recovery emerged from the grass roots of the consumer/survivor movement during the latter part of the 1980s and early 1990s, particularly in the United States (Shepherd et al., 2008). It has entered into the professional domain and is now at a point where recovery, or perhaps more accurately a professionally embraced interpretation thereof, is beginning to influence the creation of top-down governmental policy [Department of Health (DOH), 2009, 2011].

Typically, the professional mental health literature contrasts the ideas of personal recovery with those of clinical recovery. Clinical recovery is pitched as the medical view of symptoms going into remission and/or being ‘managed’ by treatment – typically by means of medication (Slade, 2009). Personal recovery, in contrast, is seen as living well and fruitfully in spite of or in the face of continued difficulties with so-called mental health problems (Slade, 2009). The most widely cited definition is that of Anthony (1993, p. 17):

Recovery is a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills, and/or roles. It is a way of living a satisfying, hopeful, and contributing life even within the limitations caused by illness. Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness.

So, recovery originated from service-user/consumer/survivor accounts of how mental illness can be overcome and, to some extent or other, recovered from. Some of these hopeful stories or narratives emphasize how life can be worthwhile in the face of mental illness, and there are yet others expressing ideas of complete recovery. Perhaps it is better to think of self-discovery or self-transformation as a key component of these stories rather than ‘recovery from’ a mental health difficulty. An argument against recovery that was presented at a recent international refocus on recovery conference was that it is still too closely tied to medicine and entails a belief that there is ‘something wrong with the person’ that necessitates recovery (Beresford, 2012). The present literature on personal recovery indeed presents a partial recovery picture or one in which the recovery is centered around not so much the resolution of the ‘illness defined’ portion of the person’s functioning as those other areas of life that are initially obstructed or impaired because of the arrival of ‘mental illness’.

A lived experience perspective on recovery

My own recovery from psychosis was one that took at least five years from the last active experience of persistent unusual beliefs and thoughts. I present my recovery journey, what that was like and how I reached a point of complete...

Table of contents

• Cover
• Title
• Copyright
• Dedication
• Contents
• Acknowledgements
• Foreword
• 1 The aims and intentions of recovering from psychosis: Empirical evidence and lived experience
• 2 Introduction to psychosis, recovery, post-modernity and trans-modernity
• 3 An autoethnographic account of psychosis in the context of neurobiological, cognitive psychological and meta-synthetic analysis
• 4 A review of current UK treatment approaches to psychosis: Surveying contemporary interventions and their empirical status
• 5 Research into recovery from psychosis: An empirical review and critical reflection
• 6 Recovery, psychosis and identity
• 7 Political dimensions of recovery
• 8 Measuring recovery: The tyranny of psychometry
• 9 Beyond recovery: Towards mental health as well-being
• 10 Reflections upon recovery: The person is political
• Bibliography
• Index