[spiritual_emergency]

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This paper will describe the process of making sense of psychotic experiences and promoting recovery for people who are receiving psychiatric treatment. It will focus on some of the concepts, therapeutic strategies and actions that are likely to help the recovery process. I am a clinical psychologist who has spent the last nine years working psychosocially with people whose problems have been diagnosed as psychotic. I have also had the experience as an 18-year old of receiving psychiatric treatment for psychosis and being diagnosed with schizophrenia. I will consider some of the basic principles we can learn from the growing recovery literature in order to better promote self help and recovery for the person who has psychotic experiences. I will envisage the different ways that we as professionals and patients might understand psychotic experiences as meaningful events in the context of people’s social lives. I will argue that rather than attempting to reduce psychotic experience the focus of our work should be on reducing the debilitating nature of the experience so that people can freely get on with their lives. I aim in this chapter to reflect on practical considerations for working with psychosis that derive from both subjective wisdoms as well as the usual professional sources.

1. Clinical Language
Being given a diagnosis of schizophrenia was not helpful for me. It created a learned hopelessness in me and my family who resigned themselves to the established belief I would always be ill, unable to work and always need antipsychotic medication. There is a deeply held assumption that schizophrenia is a disease-like degenerative process. Thus the category of schizophrenia is associated with a failure to recover and a gradual deterioration in social functioning. It is more helpful to see each individual’s mental health as a unique and evolving story, which is importantly influenced by social and relational experiences.

Compared with traditional diagnostic categories, a focus on individual experiences provides a better framework for understanding psychosis on both empirical and practical grounds. The British Psychological Society Report Recent Advances in Understanding Mental Illness and Psychotic Experiences, suggested individual formulations may be more useful than diagnostic categories. Moreover there is generally a practical benefit to moving away from clinical language and the concept of mental illness to a more holistic flexible language about ‘mad’ experience. Traditionally clinical language has risked colonizing people’s experiences and beliefs. ...

2. Recovery Processes
The concept of schizophrenia was unhelpful to me. A more helpful concept would have been recovery, but unfortunately this was never discussed. In discussing recovery I am not implying the medical concept of ‘cure’. Rather I am using the definition made by Anthony who suggests that recovery from serious mental health problems is a multi-dimensional concept: social and psychological recovery processes are seen as being as important as clinical recovery. Clinical recovery is defined by reduction in ‘symptoms’ (e.g. voices and unusual beliefs). Social recovery describes the development of meaningful social relationships and roles, vocational activities and access to decent housing. Psychological recovery describes the process of developing ways to understand and manage psychotic experiences and regain some sense of structure in one’s life. These distinctions are important as currently services and research focus too heavily on clinical recovery. ...

2a) Recovering Social Identity
Initially when a person realizes that they have been identified as psychotic and are therefore different to others, a sense of loss of one’s normality often follows. This can feel very threatening. Cast as psychotic one has entered a taboo identity in Western society, with connotations of being socially, morally and genetically inferior. A real sense of social failure and despair can set in. In addition one may feel disabled by the psychotic experiences themselves. At the time of hospitalization I found it useful to see myself as ‘burnt out’ - that I needed rest but that I could make a full recovery. However I knew that I could not go back and undo the fact that I had ‘gone loopy’. It took me some time to come to terms with this. Consequently, there may be a period of time when one has to mourn the loss of a former identity and reassess one’s expectations and values. Many people going through this will value the information in the normalizing literature. ...

2b) Recovery and Narratives of Possibility
My recovery was about gaining other people’s confidence in my abilities and potential. Behind that there was the physical recovery, which required rest, therapeutic activities and good food. However the toughest part was changing other peoples’ expectations of what I could achieve. It involved seeking out contexts where my contribution was welcomed and valued. To approach new settings with confidence it was important for me to resist adopting an identity dominated by an illness model. ...

2c) Recovery Themes
From the studies that have looked at personal recovery accounts I will describe some recurrent themes:

c1. The importance of supportive others: A consistent theme in accounts of recovery is that there is always at least one person who has stood by that person, treated them with dignity and valued them. Having people around you who give you space but who also believe in your abilities and potentials is a huge asset. ...

c2. Hope: Hope is a key ingredient in successful recoveries. Traditionally this has been lacking in mental health services. Therefore stories of success are important ingredients in both information given to service users and training for mental health workers. From my own experience positive stories written by people who have made good recoveries would have been very hope-giving and inspirational. Therefore every Early Psychosis services should have a ‘recovery library’, containing positive media and personal accounts of experiencing psychosis and getting on with one’s life. Involving mental health workers who have experienced psychosis in early intervention programmes is another excellent way to promote positive expectations of people’s outcomes.

c3. A coherent account of experience: Ridgeway’s review of recovery accounts concluded that whilst denial may be an important initial coping strategy, coming up with a way of understanding one’s difficulties, is an important aspect of recovery. However Ridgway observed that adopting an illness model is not necessary for recovery. Recovery does not require a singular view of psychosis. ...

c4. Spiritual beliefs: Spiritual beliefs and activities are reported widely to be helpful in people’s recovery stories. Acknowledging the importance and validity of spiritual belief systems and activities, allows the person to maintain authorship of their life in the way that works most fruitfully for them. There is scope for good partnership work with local religious organizations, which have a different yet often valuable wisdom about healing and recovery processes.

c5. Building a Positive Personal and Social Identity:
This is about gaining access to conversations and activities that enable one to feel good about oneself. However this is not about promoting a relentless self-awareness. ... It includes having opportunities to carry out valued activities that contribute to and introduce one to the world of others so that one is less preoccupied with one’s own inner world. ... Such psychological assets do not exist in a social vacuum. For many people progressing in their social recovery may be about searching for contexts where their abilities and attitudes are noticed and appreciated. ... ‘Recovery groups’ where members are encouraged to share stories and learn skills together (e.g., personal development, social awareness etc) and exchange self-help strategies, are effective at building morale and competency for many. ...

c6. Becoming Active; the individual moving to a position of taking responsibility for, and active involvement in his/her recovery: Traditionally mental health services have to some extent encouraged passive adjustment to an assumed ‘illness’. The recovery literature suggests this is only likely to foster dependence and passivity. Rather, the challenge is to create environments that recruit the person as an active agent in their recovery. This is likely to evoke a more functional sense of self. Thus a recovery oriented service needs to offer accessible information and choices to the people they are working with; share decision-making; negotiate care; encourage the use of advance directives; support people to take informed risks. ...

2d) Emotional Recovery: Traditionally, professionals’ approach to psychosis has prioritized thought disorder over the emotional content of psychotic experiences. Whilst it has been assumed some empathic work takes place, this has not been emphasized sufficiently. I would like to suggest that emotional work is crucial to consider in addressing psychotic problems.

2e) Psychosis as a Post-Traumatic Reaction: Romme and Escher (2000) described how for voice hearers the emotional processes recognised as important to recovery from trauma are extremely relevant. Romme and Escher’s work suggested that many psychotic experiences are linked to earlier experiences of trauma. Many studies have found a high correlation between psychotic experience and past experiences of adversity and trauma. Many personal recovery accounts report finding emotional explanations useful in making sense of their experiences. ... An advantage of the post-traumatic explanation of psychosis is that it gives the psychotic process a functional role. Rather than being just an affliction, such psychological processes as splitting off from experience and dissociation, can be seen as adaptive strategies that have enabled the person to survive adversity. For many this is a more coherent and enabling story than the bio-medical narrative about psychosis. Therefore it is worth reflecting on the circumstances which aid recovery from trauma.

2f) Living and Coping with Alternative Beliefs: Kaffman, in a study of 34 families where there was a ‘paranoid patient,’ found that firstly, there was always an element of truth and reality underlying persecutory belief systems and secondly, that past and present relationships played an important role in generating and activating the beliefs. Exploring the meaningfulness of people’s persecutory beliefs and their relevance to their social lives and past experiences is often an extremely helpful and validating process. Persecutory beliefs that appear delusional to professionals often have significant metaphorical and affective value for the person. Thus they may represent real experiences of persecution and powerlessness. ...

3. Medication: The psychological effects of neuroleptic drugs are important to consider in any psychological approach with people being treated for early psychosis. Though these drugs are often described as antipsychotic, neuroleptic (meaning ‘nerve seizing’) may be a more accurate description of their action. What is the experience of taking neuroleptic drugs like? David Healy in his book ‘Psychiatric Drugs Explained’ described how in the 1950’s the original understanding of how neuroleptics worked concluded that they produced a feeling of detachment - of not being bothered by what had previously been bothering. This description very much fits with my own experience of neuroleptics. Unfortunately this ‘feeling of detachment’ not only applied to my disturbing ideas but also to recovery processes such as creative thinking, problem solving and motivation to pursue purposeful activities. There is a danger that if anti-psychotic medication is used in a long-term fashion, its dissociative effects may suspend individuals’ abilities to recover complex psycho-social abilities.

4. Working with the whole person; Valuing the person’s subjective perspective and wisdom: A recovery oriented approach suggests a move away from observing the person’s behaviour and trying to interpret it in terms of clinical models to an approach that starts from valuing and respectfully understanding the person’s experiences from their perspective. This is about a whole person approach, working on the problems that the client presents in the way they want to work with them.

Adopting a whole person approach means that a consideration of the person’s present difficulties with psychotic experiences, needs to be balanced with an appreciation of important non-clinical aspects of personhood. These include a consideration of the person’s developmental life experiences, their achievements, their abilities and potentials. Social references of personhood also need consideration. For example, the gender, family, peer, aesthetic and cultural contexts that the person defines themselves within.

Culture and a whole person approach: It is important to consider the impact of different cultural expectations on how clients might want to respond to their difficulties. ...

Conclusion:

Psychosis is not just an individual problem. My own ‘madness’ was about dis-connecting from a world I struggled to identify with. Therefore in my work with people I am keen to consider how can we make the world around them one that is worth connecting to and negotiating with.

Traditionally the problem with being seen to be psychotic is that one is isolated with this experience, set aside as fundamentally different and inferior. The way to combat this isolation is to create safe spaces where unusual experiences can be shared and made sense of. As soon as we start to share commonalities the power of the isolation of the experience is broken down. Meaningful accounts of psychosis that allow us to connect with others and make choices about our lives are essential to any recovery process. In sharing unusual experiences and different ways of making sense of them we are no longer mad. The experience that is identified as psychotic can be incorporated into social identity, using a range of explanatory frameworks, including emotional, spiritual and psycho-social paradigms. Therefore being prepared to think flexibly about our approach to people with psychotic experiences on an on-going basis is an important part of developing recovery-oriented services.

Services for psychosis have traditionally employed overly medicalized and didactic treatment approaches. Creating a more enabling approach involves recruiting the expertise of personal experience into therapeutic services. Recovery stories are an important source of hope and motivation for people with psychotic experiences. Recovery accounts demonstrate that people benefit from being able to make sense of their psychotic experience in the context of their past and present social experiences, in the way that feels most comfortable to them. Making sense of psychosis and engaging in meaningful activities also requires reliable and enabling community networks. Truly helpful services enable people to take an active role in their recovery. Such services are likely to be those which avoid imposing clinical labels and definitions, stress the possibilities for recovery, adopt a collaborative approach to decisions about therapies and relate to the person rather than the ‘symptoms’.

Source: <a href=http://www.brad.ac.uk/acad/health/research/cccmh/files/UnderstandingPsychoticExperience.doc>Dr. Rufus May: Understanding Psychotic Experience and Working Towards Recovery [PDF File]</a>