Recovery after psychosis: a compassion focused recovery approach to psychosis in a forensic mental health setting

Over the past fifty years, there has been significant improvement in the expected outcomes of individuals with psychosis, due to advances in psychotropic medication, and through the development and application of psychological approaches such as Cognitive Behavioural Therapy. Such improvements in outcome have been demonstrated through various outcome studies and meta-analyses of outcome studies. However, the recovery/consumer movement has criticised outcome studies on the basis that they focus on symptomatic outcome and do not incorporate into their studies measures of outcome as defined by individuals who experience psychosis. The aim of this thesis was therefore to explore the experiences of individuals with psychosis in a forensic mental health setting. The objective was to develop recovery focused psychological interventions based on patients’ experiences of what helped them to cope in hospital, and in essence, what they valued in their recovery. The first study employed a social constructionist version of grounded theory methodology to explore the experiences of patients residing in a secure hospital. Thirteen individuals who had experience of psychosis were interviewed in depth about their experiences of recovery. Contrasting accounts of recovery were apparent from the way in which participants spoke about their experiences. Some participants gave rich and reflective accounts of their recovery. These participants spoke about the nature of their past experiences, the importance of those experiences in contextualising their problems and reflected on the implications of this on the tasks of recovery. In contrast, other participants’ transcripts tended to be short and unelaborated. Recovery tasks seemed to be segregated from previous experiences and their reflection on their experience of psychosis seemed minimised. All participants spoke about the importance of developing their sense of self, and the importance of developing relationships with staff and with family. This study is presented in Chapter Four. The findings of the grounded theory study led to the development of a self-esteem intervention. Research has shown that low self-esteem is common in individuals with psychosis (Bowins & Shugar, 1998; Silverstone, 1991), and that it is implicated in the development and maintenance of psychotic experiences such as delusions and auditory hallucinations (Garety et al., 2001; Smith et al., 2006). This intervention was based on a previous study carried out by Hall and Tarrier (2003), but adapted for delivery in a group setting in a secure hospital. Fifteen patients completed the self-esteem group intervention and significant improvements were found on self-esteem and depression. These improvements were maintained over a three month-follow up period. This study is reported in detail in Chapter Five. A recovery group was developed after this. The modules in this programme were developed from the themes of the grounded theory study and the observations made during the self-esteem programme. The recovery group was based on Compassion Focused Therapy (CFT, see below) and aimed to promote emotional recovery with the aim of improving self-soothing, coping with distress and the development of inner warmth. This programme was developed following observations that although individuals in the self-esteem group could challenge self-critical thoughts through the use of skills they had acquired in the group, they reported that they continued to feel negative and worthless about themselves. Compassion Focused Therapy (CFT) was developed by Gilbert and colleagues (Gilbert, 1992, 1997, 2000; Gilbert and Irons, 2005) for individuals with shame and self-critical and attacking thoughts. It is based on social mentality theory (Gilbert, 1989, 2001, 2005), which explains how people come to experience an internalised self-attacking narrative. This often develops as a result of trauma, abuse and loss and results in an individual experiencing shame and feeling a sense of threat. It also has implications for an individual’s ability to cope with distress and to regulate affect. The purpose of CMT is therefore to help individuals move from a self-attacking style to one of self-soothing and compassion. It is anticipated that this style of self-relating will promote recovery and enable individuals to be less critical about themselves and their experiences and so, be able to seek help should they face relapse in the future. With this in mind, the Recovery After Psychosis (RAP) programme was piloted and eighteen individuals completed the group. Significant effects were found for depression, self-esteem and an improvement in sense of self compared to others. This study is discussed in Chapter Six. The findings of the studies contained within this thesis are further discussed in Chapter seven. The findings are compared with previous studies on recovery, and also compared with other interventions employing compassion-focused approaches. The limitations of the research in this thesis are discussed. A model of compassion focused service delivery is described along with implications for future clinical practice and research.