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Chapter 1
Psychosis and emotion
The role of emotions in understanding psychosis, therapy and recovery
Andrew Gumley, Alf Gillham, Kathy Taylor and Matthias Schwannauer
Introduction
This book aims to bring together a collection of current, fresh and original perspectives on contemporary international work with psychosis, under the aegis of the International Society for the Psychological Treatments of the Schizophrenias and Other Psychoses (ISPS), which has a long and distinguished history of building bridges between differing approaches to psychosis. As editors, all practitioners of psychotherapeutic work with psychosis in the UK, we share a passionate interest in broadening the base of theory considered relevant to our clinical work.1 Recently the dominant psychotherapeutic model has been a cognitive-behavioural approach to working with psychosis, particularly as a variety of convincing randomised controlled trials (RCT) have demonstrated the effectiveness of cognitive-behavioural therapy (CBT) for reducing distress and improving coping with psychotic symptoms. However, in clinical practice a wide range of concepts and ideas is drawn upon with increasing importance being placed on developmental processes, emotional processing, trauma, early experiences, close interpersonal relationships, family and organisational systems in the evolution and expression of psychosis.
We have approached a range of authors from different theoretical backgrounds to provide a rich, varied and distinctive range of perspectives on the importance of emotion in understanding and helping people with psychosis. In doing this, it is our expressed aim to give voice to this range, which we believe can introduce richness and complexity into our growing understanding of this challenging area. We do not attempt to integrate these different perspectives; some are really quite different in essential ways. We hope that this collection will inspire a discourse on the role of affect and distress in psychosis, which is driven by different theoretical and psychotherapeutic perspectives. However, this introduction to the text aims to provide some commentary on and linking between the chapters contained within the book, without losing the diversity we are presenting here.
Since the concept of schizophrenia was introduced in 1911, emotion has been at the heart of understanding psychosis. Over the years this emphasis on emotion and affect as an essential aspect of the disorder has been replaced with increasingly biological and neurophysiological paradigms and a disproportionate focus on positive symptoms of psychosis. A revitalisation of concepts and theories of emotion and psychosis, especially in the context of psychological and psychotherapeutic treatments, is long overdue and we have chosen this portal with which to make an entry into publishing some emerging and stimulating therapeutic treatment models. In this volume we emphasise the importance of emotion in psychosis and explore how thinking about affect can contribute to care, psychotherapeutic intervention and recovery. We will now aim to highlight how each of the authors has approached the complex relationship between emotion and psychosis from their own perspective.
In Chapter 2, Andrew Moskowitz and Gerhard Heim give an important and essential insight into the role of emotion in schizophrenia, returning to the essential components of Bleulerâs historical concept. Moskowitz and Heimâs chapter reminds us that the original conception of schizophrenia was closely linked to the development of psychoanalytic thought. Eugen Bleuler and Carl Jung collaborated on the further development and refinement of Wundtâs word association test at the Burghölzli as a means of revealing the psychological and emotional significance of individualsâ responses to word stimuli. It is through this association with Jung that we can understand the psychological roots of Bleulerâs concepts of âloosening of associationsâ and âemotionally-charged complexesâ. Moskowitz and Heim argue that Bleulerâs concepts of âsplittingâ and âcomplexesâ, central to his concept of schizophrenia, are interestingly quite close to the contemporary concepts of dissociation and dissociative identities. Later psychoanalytic theorists working to understand psychosis, especially the post-Kleinians, Segal and Bion (see Lucas, 2009), saw this extreme separation, or splitting, as a particular feature of psychotic symptoms where immediate perceptual experience becomes divorced from its emotional significance and meaning, and then further fundamental disturbance of psychic functions might also occur, as Bleuler originally proposed. Moskowitz and Heimâs chapter is important because it enables us to revisit these original conceptualisations that have all too easily become lost through time.
Emotion and the therapeutic relationship
As an important aspect of our book, Chapters 3, 4 and 5 focus our attention on the expression of emotion in the context of the therapeutic relationship. Garfield (1995) has previously argued that unbearable and unintegrated affect lies at the core of psychosis and that repair following psychosis involves the processes of acknowledging, bearing and putting in perspective the intolerable emotions, which often have their origins in early development. In Chapter 3, David Garfield and his colleagues argue that it is the reworking of emotion and psychosis, the expanding of the individualâs emotional subjective life that becomes the primary goal of treatment. Key to this reworking of emotion and psychosis is the centrality of affective attunement as a core process in bringing about an integration and understanding of psychotic experiences. This can be a painful process since emotional experiences and meanings have their roots in often difficult experiences containing powerful affects which are not necessarily readily accessible verbally. Simultaneously Garfield reminds us powerfully that this is also a challenge for the psychotherapist â to be emotionally available and to be able to respond to and create a safe context for recovery to unfold, making a link with Bionâs notion of âcontainer-containedâ. This introduces an important and crucial theme in the book, which is the central importance of the therapeutic relationship. This theme is particularly exemplified in the following two chapters.
In Chapter 4, Sarah Dilks provides a dialogical view of change processes in psychological therapy. Dilks shows how the co-construction of a narrative provides a context for understanding how processes of managing painful emotions and developing new insights and perspectives unfold within psychological therapy. The core process of âbuilding bridges to observational perspectivesâ provides a means of conceptualising conversational processes in therapy, where new perspectives are continually and jointly created by the client and therapist as a means of opening up new possibilities for thoughts, emotions and coping. This does not happen by accident: rather the therapist provides the emotional containment and scaffolding to create opportunities for the processing of emotional distress and the development of activities focused on managing and mastering difficult emotions. Dilksâs chapter wonderfully illustrates these concepts through detailed and vivid accounts taken from clients describing their experiences of different psychological therapies.
Building on the role of the therapist scaffolding the unfolding of a conversational process enabling the emergence of new perspectives, Susanne Harder and Paul Lysaker explore this further in Chapter 5. They show how the formation of the early therapeutic relationship shares basic principles of interpersonal attachment similar to how mothers and infants form the initial relationship prior to language acquisition. They show how findings on optimal interpersonal interactions between mothers and infants are understood within a balanced model of self and interactive regulation. This is crucial to the development of a secure attachment that can be utilised to develop strong working alliances, which often require a complex and lengthy process of therapeutic engagement. This illustrates how for some individuals and their therapists the development of a therapeutic relationship can be difficult, complex and challenging. Together, Chapters 3, 4 and 5 show us from differing perspectives the verbal and non-verbal processes which enable regulation of internal states and experiences, and how these states manifest in the context of an emotionally attuned therapeutic relationship, and the transformation of these into productive and meaningful forms of language that co-create and release new understandings, perspectives and reactions to promote recovery.
The wider context of emotion
Moving from the context of the therapeutic relationship, the book turns its focus to give consideration to the attachment context of affect and affect regulation (Chapter 6); how this manifests from the perspective of wider organisational and professional caregiving considerations (Chapter 7); the cultural and societal (Chapter 8) and the systemic and familial (Chapters 9 and 10) contexts and experiences of psychosis. Building on the emergent themes concerning past and current relationships and the concept of attachment, in Chapter 6, Matthias Schwannauer describes an attachment-based understanding of mentalisation and reflective functioning. Psychosis involves the disruption of social relationships and the understanding of self in relation to others. In this context psychotherapy can directly address the development of a mentalising capacity to enable the clarification of sensitisation to and tolerance of complex affects. Enhancement of capacities to recognise and relate to emotional and mental states in self and others is key to the development of a coherent sense of self.
In Chapter 7, Robert D. Hinshelwood explores, in a thought-provoking way, the professional caregiving context of psychosis. He argues that psychiatric culture can struggle to enable staff to develop meaningful understandings of psychosis and to deal with the emotional impact that the care for individuals with psychosis can have on them. As highlighted by Garfield and colleagues (Chapter 3), Dilks (Chapter 4) and Harder and Lysaker (Chapter 5), the development of attuned understandings of psychosis and capacities to tolerate painful, sometimes unbearable, affects, coupled with the development of helpful forms of conversation, is a skilled activity necessitating a safe organisational and caring environment that can permit and enable these skills and activities. Organisations that often lack these capacities to contain and explore difficult emotions and experiences therefore foster greater feelings of anxiety, threat and helplessness amongst staff in relation to supporting individuals with psychosis. In response to this, organisations can then react in ways which dehumanise, stereotype, scapegoat or depersonalise service users. This can be through processes of disembodying the person from their symptomatic experiences (for example, focusing on unidimensional understandings of psychosis) or seeing individuals as not being capable of or motivated for recovery. Hinshelwood succeeds in creating a sense of discomfort at becoming aware of our own unwanted feelings that can occur in relation to working with psychosis, but importantly this chapter is an important call for developing compassionate understandings of why organisations and care staff may act in ways that disempower individuals.
Michelle Campbell, Rory Byrne and Anthony P. Morrison also explore the dehumanisation of individuals with psychosis in Chapter 8. They focus on the importance of discrimination against individuals with psychosis and the presence of stigmatising attitudes. Campbell and colleagues show the importance of recognising stigmatising representations against people with psychosis and their implications for public mental health and the design of clinical services. Such attitudes have important implications for individuals with psychosis in terms of acting as an external barrier to recovery, where external stigma generate actual experiences of discrimination and social exclusion. In addition, stigmatising attitudes are also internalised, leading to reduced help seeking and prolonging the duration of untreated psychosis. These factors can create a vicious cycle leading to feelings of social anxiety, depression and social isolation yet further reducing self-esteem. Issues of stigma have important implications for the design of public health and community-based strategies aimed at enhancing mental health literacy and enhancing access to user-focused services.
Since its original conception, expressed emotion (EE) has been a major construct in understanding the importance of family context in shaping the expression of recovery in people with psychosis (Brown et al., 1972). In Chapter 9, Frank R. Burbach has provided an excellent review of the current status of the EE construct and a systemic formulation of the role of the affective environment of the family system. He argues elegantly that any understanding of the family emotional climate and outcome of psychosis must incorporate an interactional understanding of how the language people use shapes and defines the unfolding of appraisals and the expression of affect. This formulation of the role of interpersonal processes in the formation and development of attributions which underpin expressions of criticism, hostility and warmth opens up new systemically based family interventions. Complementing Burbachâs analysis, Paul Patterson (Chapter 10) offers a developmentally based analysis of the role of attachment and loss in the evolution of expressed emotion. Psychosis can be understood as a highly distressing life event, which acts on the family attachment system. In Bowlbyâs (1980) formulation of attachment theory, illness was understood as a key life event acting on the attachment system. Through the development of internal working models (IWMs) the attachment system organises individualsâ affectional and affiliative bonds, providing an adaptive context to regulate painful emotions and experiences. Patterson argues that in the context of psychosis, individualsâ and carersâ internal working models are activated and trigger potentially disorientated or disorganised attachment behaviours through feelings of threat, separation and loss. It is out of these fundamental experiences of the threat of loss, separation and harm that painful and difficult emotions emerge, which often remain unintegrated. Pattersonâs model helps us understand the developmental and attachment based roots of criticism and hostility as an adaptive response to the threat of loss.
Theoretical perspectives and new horizons
We now turn our attention to a series of chapters that offer new and developing theoretical insights from psychoanalytic theory (see Chapter 11), and evolutionary psychology (Chapters 12 and 13). In Chapter 11, Michael Robbins makes the important distinction between affect on the one hand referring to fundamental somatosensory experiences, and emotion on the other referring to the thoughtful awareness and mental representation of feeling states. In making this distinction Robbins helps us understand his psychoanalytic perspective on psychosis where unregulated sensations, perceptions and affects express themselves in psychotic experiences. In common with other chapter authors, he also makes us aware, through his use of a clinical illustration, that the process of becoming conscious of the emotional meaning of the underlying affect can be a painful experience for both patients and therapists, requiring considerable tolerance and capacity.
In Chapter 12, Andrew Gumley and Max Birchwood outline the key role of shame in the evolution of emotional distress after psychosis. They particularly focus on the experience of depression and social anxiety, both of which are underpinned by a sensitivity to social identity threat and stigma. They propose that, as a means of coping with social identity threats, individuals submit or subordinate to externalised negative stereotypes of mental illness. As a consequence of these processes of subordination, experiences of depression, hopelessness, fear and social anxiety emerge as unintended consequences of the personâs best attempts to cope with externalised and internalised shame and stigma of mental illness.
Finally in Chapter 13, Ross White, Heather Laithwaite and Paul Gilbert outline an evolutionary based understanding of negative symptoms as expressions of experienc...
