Self‐interpretation and meaning‐making processes: re‐humanizing research on early psychosis
Authors: Rosa Ritunnano, Giovanni Stanghellini, Matthew R. Broome
Journal: World Psychiatry (2021)

Dimensional, dynamic and transdiagnostic approaches to explaining, classifying and treating psychopathological symptoms are currently leading the way into a new era of early intervention for psychosis research and practice – beyond the "at risk mental state" concept1. While research into the clinical and biological predictors of psychosis onset is slowly advancing, we argue that the role of self-interpretation and meaning-making processes remains relatively neglected. If humans are self-interpreting agents, constantly interacting with others through culture, then meanings are likely to be a significant driving factor in the transition from vulnerable selves to persons affected by psychosis. Notably, robust evidence emerging from cognitive-oriented studies points to a central role of appraisal (i.e., the meaning and interpretation of anomalous experiences) in re-directing the phenotypic trajectory of illness towards a "need-for-care" status, as compared to a more benign non-clinical course2. This is consistent with person-centred dialectical models of schizophrenia3, emphasizing the active role of the person in shaping psychopathological syndromes. We argue that prediction research could benefit from exploring the effect of personal meanings, family narratives and cultural signifiers on the clinical outcome of pre-psychotic experiences. As a response to growing consensus in the field that current syndromic classifications do not fit the ebb and flow of emerging microphenotypes, new dynamic models of the onset of mental disorders have been suggested4. These models propose the application of mathematical principles governing complex systems to the study of emerging psychopathology in psychosis. By capturing the fast-moving and unstable nature of psychopathological states, the hope is that such models will aid prediction research and allow for the optimization of early treatments. While some of these models have been used successfully to predict the behaviour of complex systems (e.g., ecosystems and financial markets), they do not account for the fact that human beings will actively interpret and respond to changes in the coordinates of the system, thereby contributing to increasing complexity. These interpretations will partly depend upon the experiential and immediately felt quality of self/world anomalous experiences (SWAE), but also upon the collectivity of meanings, attitudes, beliefs and values as a function of the person's unique biographical, sociocultural and historical context. SWAE are increasingly recognized as core psychopathological features of psychosis, particularly within the schizophrenia spectrum. According to the ipseity disturbance model of schizophrenia5, the longitudinal progression of symptoms is driven by a gradual exacerbation of diminished self-affection and disturbed grip or hold on the world. These latter features are thought to be fairly stable and enduring vulnerabilities affecting the conventional or common-sense way of inhabiting the world. However, very little is known – and even less has been investigated empirically – about how individuals understand, make sense of, and appropriate emerging SWAE in the early stages of psychosis. How do people take a position (i.e., cope with or respond to SWAE)? What meaning resources do they turn to? What role do meaning-making processes play in the shaping of psychopathological phenomena and clinical outcomes? The idea that human beings are self-interpreting agents is not new in the phenomenological literature. On the foundations laid by K. Jaspers' account of the "patient's attitude to his illness", also called "position-taking" (Stellungnahme), other classical authors have developed dialectical models of the onset of schizophrenia (Pinel, Bleuler, Wyrsch, de Clérambault, Blankenburg, Mayer-Gross, J.S. Strauss, and others). Their models emphasize the active and dynamic interplay between the person and his/her basic experiential anomalies, suggesting that such interaction might influence the development of different schizophrenic phenotypes from the common root of self-disorders. Stemming from this classical literature, a person-centred dialectical approach to schizophrenia has been proposed6, which is concerned not only with the phenomenal level of experience (i.e., changes in the sense of self and lived world), but also with the different ways in which patients "take a position" in the face of emerging psychotic-like phenomena. This dynamic sense-making activity in the face of anomalous experiences is clearly reflected in the first-person narratives of individuals in the early stages of psychosis7. From this growing body of qualitative literature, two inextricable dimensions seem to emerge. On one level, an all-enveloping sense of unreality, threat, disorientation and uncertainty often accompanies disordered experiences of self, time, space and body. A number of phenomenologists and psychopathologists have referred to "background feelings"8 as a way to capture the subtle but all-encompassing, pervasive, atmospheric qualities of subjective life that drive our interpretation of the world. On another level, an ongoing reflective activity in the form of "searching for meaning", "making meaning" and "finding meaning" appears overwhelmingly central to the process of articulating the subjective experience of illness onset. According to the most influential phenomenological models of the onset of schizophrenia, these self-interpreting efforts are triggered by a state of "perplexity", whereby reality loses its taken-for-granted, common-sense meanings and endangers the core sense of self. Understanding how people make sense of these puzzling experiences and how these meanings impact on their behaviour is crucial in order to develop adequate dynamic models of emerging psychosis. In addition to a nuanced and in-depth psychopathological examination and clinical phenotyping, these models should also reflect the agentic role of the person in shaping the course of illness within a specific meaning-giving context. But how to account for these meanings in a way that can be effectively operationalized to inform predictive models while avoiding the de-humanization of psychiatry? Even if research shows that psychosis evolves in a staging fashion akin to the biological process of growing and spreading of cancer, we still need to deal with a distinct set of features that places the mental realm apart from the physical realm. In this sense, meanings are not only something mechanically generated by the mind in the same way as the immune system defensively produces antibodies. Meanings also respond to a fundamental human quest for coherence and purpose, prospectively shaping our way of being in the world within a value-laden framework of significance. One way in which the cognitive aspects of this human response have been operationalized is through the conception of appraisal (i.e., the meaning attributed to pre-psychotic/psychotic-like experiences). As an alternative phenomenologically-informed approach, we suggest the integration of appraisal into the construct of position-taking, which also takes into account the "background states of the person that exist before the experience and contribute to determining the experience itself"9. The principal dimensions of position-taking are: a) the person's emotional tone, i.e. the background feelings associated with the SWAE, and b) the person's working-through, i.e. the cognitive and narrative elaboration of his/her SWAE. We believe that this second level of assessment might also help shed light on the transdiagnostic occurrence of SWAE across schizophrenia, depersonalization/derealization disorder and panic disorder, but also non-clinical states such as intense introspection. Given that some of these experiential anomalies might be indistinguishable at a phenomenal level, the subsequent clinical-diagnostic trajectory might be (at least partly) driven by the kind of position-taking adopted, further influencing subjective distress and need-for-care. Improved understanding of the relevance of meaning-making in psychosis research can ultimately enhance our ability to predict the dynamic evolution of clinical high-risk states without losing focus on the person as a self-interpreting being interacting with his/her sociocultural world.