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Staying Well After Psychosis


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Table of Contents

About the Authors ix Preface xi Foreword by Max Birchwood xv Acknowledgements xvii PART I THEORETICAL OVERVIEW 1 1 Current Perspectives on Relapse, Relapse Detection and Prevention 3 Introduction 3 Psychological Therapies and Relapse Prevention 4 Affect, Meaning and Relapse 18 A Cognitive Behavioural Model of Early Signs and Relapse 23 Antipsychotic Medication and Relapse 27 Implications for Staying Well after Psychosis 32 2 Attachment Theory, Self-regulation and Psychosis 34 Introduction 34 Patterns of Attachment 36 Attachment Theory and Later Psychopathology 38 Stability of Attachment Organisation 42 Attachment Organisation and Psychosis 43 3 Psychological Factors in Vulnerability and Transition to Relapse 47 Introduction 47 The Interpersonal Context 48 The Wider Social Context of Psychosis 54 Significant Life Events 56 Trauma 57 Interpersonal Coping 59 Appraisals of Psychosis and Emotional Distress 62 Conclusions 63 PART II OVERVIEW OF STRUCTURE, STYLE AND ORGANISATION OF THERAPY 65 4 Overview of Principles and Procedures 67 Introduction 67 Primary and Secondary Outcomes 67 Assessment 68 Structure of Therapy 73 Style of Therapy 75 Basic Elements of the Therapeutic Stance 79 General Outline of Therapy Sessions 79 Service Model 84 5 Strategies for Engagement and Formulation 86 Introduction 86 Attachment Organisation, Recovery and Distress 86 Validation 91 The Evolution of Therapeutic Discourse 95 Case Formulation 97 Case Formulation in SWAP 99 Conclusions 102 PART III SPECIFIC COGNITIVE AND INTERPERSONAL STRATEGIES FOR RECOVERY AND RELAPSE PREVENTION AFTER PSYCHOSIS 103 6 Reorganisation of the Self in Recovery: Working with Humiliation, Entrapment and Loss 105 Introduction 105 Life Events and their Dimensions 106 Bowlby on Loss 109 Clinical Interventions and Techniques 111 Conclusions 122 7 Working with Interpersonal Distrust: Developing a Conceptualisation of the Paranoid Mind 124 Introduction 124 Paranoia as an Interpersonal Threat Response 124 The Paranoid Mind is Strategically Deployed 126 Attachment and Paranoia 126 Problems with the Term `Paranoia' 128 Working with the Personal Distress of the Paranoid Mind 129 Awareness of the Paranoid Mind 132 Development of an Accepting Rationale for Paranoia as a Response 133 Benefits and Costs of the Paranoid Mind 135 Development of Alternative Interpersonal Strategies 137 Conclusions 138 8 Working with Traumatic Reactions to Psychotic Experiences 140 Introduction 140 Psychosis as a Traumatic Event 141 Trauma Theory 144 Assimilation and Accommodation 147 Exploring Traumatic Reactions 150 Explaining Traumatic Reactions 152 Exploring Meaning within Traumatic Memories and Imagery 154 Contrasting Experiences of Psychosis and PTSD 158 Conclusions 160 9 Interpersonal Strategies 161 Introduction 161 The Social Environment 161 Interpersonal Environments as a Basis for Psychological Intervention 165 The Role of Interpersonal Anxieties and Social Withdrawal 167 Areas of Interpersonal Difficulties 173 Working with Interpersonal Sensitivity 177 Conclusions 181 10 Working with Underlying Schemata and Core Beliefs 182 Introduction 182 Early Parental Loss and Psychopathology 182 Childhood Abuse and Neglect 183 Psychological Sequelae of Childhood Abuse and Neglect 183 Unresolved Attachment Status 185 Early Childhood Trauma and Psychosis 186 Trauma, Dissociation and Schizotypy 187 Schemata and Internal Working Models 189 Identifying Schemata 192 Schemata and Behaviour Relationships 193 Core Belief Change Strategies in Cognitive Therapy 195 Working with Underdeveloped Strategies 196 Conclusions 201 11 Awareness, Intrusiveness and Fear of Relapse 202 Introduction 202 Phenomenology of Relapse 202 Subjective Experiences and Psychosis 203 Appraisals and Relapse 205 Awareness, Intrusiveness and Fear 206 Cognitive Behavioural Therapy (CBT) and Relapse Prevention 209 Exploring Experiences of Relapse 210 Explaining Beliefs 212 Early Signs Monitoring 213 The Initial Interview for Targeted CBT 214 Testing the Formulation 215 Decatastrophising Relapse 215 Contracting Intervention 216 Subsequent Sessions 216 Introducing Flexibility into Beliefs 218 Transforming Beliefs 219 Testing Transformed Beliefs 221 Conclusions 222 12 Conclusion 224 Introduction 224 Overview of the Treatment Manual 224 Therapist Training 229 Therapeutic Context 229 Appendix I Fear of Recurrence Scale (FoRSe) Questionnaire 231 Appendix II Diagrammatical Formulation of Early Signs 233 Bibliography 235 Index 283

About the Author

Andrew Gumley is Senior Lecturer in Clinical Psychology on the University of Glasgow Doctorate in clinical Psychology training Programme, a practising clinician as Honorary Consultant Clinical Psychologist in ESTEEM, North Glasgow Early Intervention Service, a trainer in cognitive behavioural psychotherapy at the Glasgow Institute for Psychosocial Interventions (GIPSI) and external consultant to the State Hospital at Carstairs Psychosocial Interventions Programme. His research interests include the evaluation of cognitive behavioural therapies for individuals who are considered to have seer and enduring mental health problems. In recent years, he has contributed to a number of randomised controlled trials of cognitive therapy involving individuals who have had or are recovering from distressing psychotic experiences, and individuals who have been diagnosed with borderline and antisocial personality disorders. His primary clinical and research interests focus on developing a psychological understanding of individual vulnerability and transition to he recurrence of psychosis. In this context Andrew is particularly interested in how the interplay between the experiences of psychosis and cognitive and interpersonal factors may prevent detection of at-risk mental states for relapse, contribute to affect dysregulation during relapse, or result in persistent and distressing emotional states such as fear of recurrence. These clinical and research interests are directed towards the development, refinement and evaluation of psychological therapies for recovery and staying well after psychosis. Matthias Schwannauer is Lecturer and Research Supervisor in Child and Adolescent Clinical Psychology on the University of Edinburgh Clinical Psychology Training Course, Research Co-ordinator in the Young People's Unit in Edinburgh and Practising clinician as consultant clinical Psychologist in an adolescent onset psychosis service in Lothian. His current clinical and research interest include the relationship between interpersonal and cognitive factors in developmental models of server and enduring disorder groups. He is particularly interested in the developmental onset of sever mental health problems with regard to psychological factors of vulnerability and resilience to psychiatric disorders. In the past few years Matthias has investigated developmental models of interpersonal and cognitive aspects of emotion regulation in a number of populations, such as depression in a highly vulnerable group of single, young homeless adolescents with an early onset psychosis and individuals suffering from bipolar disorder. He is interested in the advancement of a developmental psychopathology model of affect regulation in a range of populations with severe and recurring psychological difficulties.


"...extends our understanding of psychosis...extremely helpful for therapists working with psychotic patients who are at risk of relapse." (Behaviour and Cognitive Psychotherapy, May 2007) "Represents a giant step forward in the treatment of schizophrenia. A must for all mental health professionals dealing with this condition." Aaron T. Beck, University Professor of Psychiatry, University of Pennsylvania, USA

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