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A psychological approach to preventing relapse in psychosis
Contents
1. Cognitive behaviour therapy for psychosis
2. Psychotic relapse as an outcome of affect (dys)regulation
3. Barriers to help-seeking
4. Supporting help-seeking via CBT for relapse prevention
5. Developmental and interpersonal roots of recovery from psychosis
6. Conclusions
7. References
Relapse prevention for individuals recovering from psychosis may be better informed by attachment-based models of emotional regulation than by current cognitive behavioural approaches, writes Andrew Gumley
Sustaining recovery in the early phase of psychosis is crucial. The early years following a first episode of psychosis are widely considered the critical period that determines long-term outcome[ 1] — and the recurrence or relapse of distressing psychotic experiences is one of the most crucial factors in determining the long-term course. Relapse occurs in 20-35 per cent of people at one year, 50-65 per cent at two years and 80 per cent at five years[ 2]. With each relapse, individuals are more likely to have persistent and distressing psychotic experiences[ 3], and to experience increasing feelings of demoralisation and entrapment[ 4], loss, depression and hopelessness[ 5]. Increased emotional distress has been associated with persistent distressing psychotic experiences, more involuntary (Mental Health Act) admissions, heightened awareness of the negative consequences of psychosis, greater awareness of the stigma of psychosis, unemployment, and loss of social status and friendships[ 6]. At the heart of recovery for individuals with a diagnosis of schizophrenia is the core of emotional recovery. Garfield[ 7] has argued that unbearable 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 that often have their origins in early development.
Cognitive behaviour therapy for psychosis
Evidence for the effectiveness of cognitive behavioural therapy (CBT) in alleviating persistent and distressing psychotic experiences has been accumulating rapidly in the last decade. However, the evidence that CBT is effective in preventing relapse has been disappointing[ 8]. One of the most significant trials of CBT for psychosis to date[ 9] confirmed this lack of evidence concerning the effectiveness of CBT for relapse prevention. Key aspects of CBT for psychosis have been a focus on directly addressing distressing psychotic experiences such as hearing voices and distressing beliefs such as persecutory paranoia. While this is an important and well established therapeutic approach to alleviating the distress arising from these experiences, it may be that relapse prevention requires a different therapeutic focus. This article argues that the focus of efforts towards sustaining recovery in early psychosis should be on emotional distress and the processes underpinning emotional coping.
Psychotic relapse as an outcome of affect (dys)regulation
Phenomenological evidence shows that feelings of fear, depression, helplessness, hopelessness, embarrassment and shame are common experiences prior to relapse, and that these emotional responses arise in the context of the emergence of low-level psychosis-like experiences, including cognitive perceptual anomalies, hearing voices, suspiciousness and interpersonal sensitivity. The combination of these experiences is sensitive but not specific to relapse. This means that while most relapses are preceded by these experiences, the occurrence of low-level psychotic experiences in combination with affective distress does not necessarily lead to a relapse. Therefore it is more appropriate to consider early signs of relapse as an 'at-risk mental state'.
Barriers to help-seeking
It is now established that the experience of psychosis is traumatic and often associated with the development of psychosis-related post-traumatic stress disorder, which is characterised by intrusive memories linked to the experience of psychosis, hypervigilance and fear, and sealing off and avoidance. The threat of recurrence of psychosis is therefore likely to generate competing and disorientating reactions such as catastrophic appraisals of relapse, fear, vigilance and interpersonal threat sensitivity on the one hand, and cognitive, emotional and behavioural avoidance and delayed help-seeking on the other[ 10].
Relapse detection and prevention rely heavily on the presence of a productive and secure working relationship between service users and care providers, including health professionals. This fact is not lost on service users, who value services as a secure base for exploration and proximity seeking[ 11]. However, in addition to the personal trauma of relapse, there may well be systemic and organisational responses, based on a model with positive symptoms (such as hallucinations) as the main focus, which impede successful relapse prevention, producing a cycle of unsuccessful, thwarted or aborted help-seeking and relapse that in turn leads to expectations that services do not provide a secure base[ 12]. Given the traumatic and distressing nature of psychosis, help-seeking itself may produce fearful expectations. For instance, individuals with psychosis may fear increased medication, re-hospitalisation, and involuntary interventions such as enforced hospitalisation. Individuals might also experience feelings of shame, guilt, and embarrassment in relation to disappointing or letting down their case worker. Furthermore, many individuals find help-seeking a challenge and may have experienced their relationships and previous interactions with others (including clinicians) as unhelpful, aversive, and/or rejecting. By focusing on detection and prevention of psychotic experiences, clinicians may inadvertently create expectations of individuals to seek help in the context of high levels of distress, a context that for some individuals can outstrip their internal and external resources. This is particularly relevant for those individuals who are experiencing a protracted, difficult, and complex recovery, and may result in a defensive but understandable delay in help-seeking. This, in turn, may result in service providers unintentionally adopting more crisis driven and coercive responses to the threat of relapse, thus confirming the person's negative expectations of help-seeking and increasing their feelings of lack of control and entrapment in illness.
Supporting help-seeking via CBT for relapse prevention
In a 12-month randomised controlled trial of early intervention with CBT for the prevention of relapse in schizophrenia, colleagues and I at the University of Glasgow[ 13] randomised 144 individuals with the diagnosis of schizophrenia to CBT (n=72) or treatment as usual (n=72). CBT was delivered in two phases. An engagement phase began with a description of the psychological understanding of relapse, which emphasised how early signs of relapse (eg racing thoughts, unusual experiences, suspiciousness) can trigger negative beliefs concerning relapse (eg 'I'm going to relapse and end up in hospital'). An explanation was given of how these were linked to increased fear, depression, helplessness, and potentially unhelpful coping and interpersonal responses (eg withdrawal, avoidance of services, substance use). Participants were encouraged to evaluate this model of relapse through discussion of their own experiences. An individualised case formulation of the cognitive behavioural factors associated with relapse, and an idiosyncratic early signs monitoring questionnaire incorporating these factors was developed for each person[ 14]. Participants were encouraged to complete and return their questionnaires using a stamped addressed envelope provided for their use.
Early signs monitoring continued for the duration of the trial, and was associated with an adherence rate of 83 per cent. Targeted CBT was initiated when the early signs monitoring showed evidence of an increase in relapse risk. Targeted CBT began with a detailed assessment of the evidence for and against emerging relapse in order to ( 1) identify potential false alarms, and ( 2) provide a test of the case formulation. Thereafter, the order of treatment tasks was as follows:
• identify and target beliefs and behaviours that increase risk to self or others
• identify and target beliefs and behaviours accelerating relapse
• develop alternative beliefs and reinforce through behaviour change.
In order to reduce participants' fear and/or helplessness about relapse, early intervention was framed as an opportunity to develop mastery over an apparently uncontrollable and inevitable process. Alternative beliefs of relapse as a controllable process were developed (eg 'If I can learn to ignore unwanted thoughts, then I will be less scared') and were tested using within and between session behavioural experiments, which involved strengthening existing coping skills and/or developing novel coping strategies. Emphasis was given to developing strategies to counteract social withdrawal and avoidance, enhance coping with criticism from others, and avoid the use of alcohol and illicit drugs. In addition, cognitive and behavioural strategies were employed to reduce intrusive cognitions, such as flashbacks to previous episodes, through guided discovery and cognitive restructuring of problematic reactions involving anger, suspicion/lack of trust, helplessness, and self-blame. Targeted CBT concluded with a review of the strategies employed during treatment, and an examination of the evidence for and against participants' previous negative beliefs and alternative new beliefs concerning relapse.
The study found a significant reduction in relapse rate (18.1 percent in the group receiving CBT vs 34.7 per cent in those receiving treatment as usual), and significant improvements in psychotic symptoms, negative symptoms and social functioning in those who received CBT. In addition, those participants who received CBT reported fewer feelings of grief and loss arising from psychosis than those assigned to treatment as usual, and an improvement in self-esteem[ 15]. Acceptability of CBT was high. Of those randomised to CBT (n=2), 66 (92 per cent) engaged in the treatment. Of those who either relapsed or were deemed at risk of relapse (n=34), 28 (82 per cent) engaged in targeted CBT.
Developmental and interpersonal roots of recovery from psychosis
Since conducting this early trial, a colleague and I[ 16] have revised and elaborated this approach to relapse prevention to place affective and interpersonal factors at centre stage in our model of recovery. This is based on increasing evidence that affect regulation and coping have their roots in early developmental and attachment-based experiences. Indeed, help-seeking can best be understood within an attachment-based framework. There is now evidence to suggest that attachment security may be compromised or even disorganised in infants who are later diagnosed with schizophrenia. It has been shown that the mothers of persons who go on to be diagnosed with schizophrenia are more likely to have experienced loss or trauma in the two years prior to or after childbirth". In addition, there is evidence that being an unwanted child increases the risk of becoming psychotic in later life. Both these types of events are highly significant risk factors for infant attachment disorders. Stressful life events, such as the death or departure of a parent, also play a crucial role. It is now becoming established that attachment organisation is unstable over the long term in high-risk populations. Maintenance of attachment insecurity and transition from attachment security is predicted by stressful life events. It is significant that the AESOP study[ 18] found that separation from, and death of, a parent before the age of 16 were both strongly associated with a two- to threefold increased risk of psychosis. In addition, it is now well established that rates of trauma, including childhood sexual abuse, are prevalent in persons diagnosed with schizophrenia[ 19]. Life events such as sexual abuse, homelessness, assault and being in care predict a risk of developing psychosis after controlling for mood, substance use and interdependence of life events. Such life events are also known to lead to the collapse and disorganisation of attachment, characterised by greater difficulties in understanding one's own mind and the minds of others (mentalisation), greater fragmentation, dissociation and segmentation of episodic memories; and the use of competing and inconsistent coping responses[ 20-21].
Most recent evidence shows that attachment insecurity is associated with the use of avoidant coping strategies that correlate with problematic service engagement, including a lack of help-seeking[ 22-23]. Using the Adult Attachment Interview, Dozier and colleagues[ 24-26] have shown that psychosis is associated with an insecure avoidant attachment organisation, which in turn is associated with a closing off of affect and episodic memories associated with affect. This attachment disorganisation was also associated with a minimisation of symptoms by the person affected, reduced help-seeking, and greater caseworker and family anxiety — and it is noteworthy that most of these attachments were unresolved with respect to loss or trauma. It is also significant that such a sealed off/ avoidant style of affect regulation is likely to locate greater anxiety in busy case workers, and may produce greater use of more catastrophic or coercive strategies in community-based teams, thus maintaining a sense of relational insecurity and entrenched non-engagement.
Conclusions
Recent evidence from our group as well as others strongly suggests that a focus on emotion and the processes of emotion regulation are key to the detection and prevention of relapse in psychosis. There is a need now for helping professionals to translate these findings into the context of (a) the availability of supportive (and non-catastrophic) service responses to the threat of relapse and (b) the developmental and interpersonal roots underpinning individuals' capacity to seek help in the context of increased emotional distress. Therapeutic processes need to be tailored to individuals' strategies for regulating distressing emotions and relational (in)security. Thus relapse prevention for individuals recovering from psychosis may best be informed by attachment-based models of emotional regulation rather than psychological models of psychotic experiences.
'Many individuals find help-seeking a challenge and may have experienced their relationships and previous interactions with others (including clinicians) as unhelpful, aversive, and/or rejecting'