Social influences on the relationship between dissociation and psychotic-like experiences.

BACKGROUND: Shame is experienced as a threat to social self, and so activates threat-protective responses. There is evidence that shame has trauma-like characteristics, suggesting it can be understood within the same conceptual framework as trauma and dissociation. Evidence for causal links among trauma, dissociation, and psychosis thus warrant the investigation of how shame may influence causal mechanisms for psychosis symptoms. METHODS: This study tested the interaction between dissociation and shame, specifically external shame (feeling shamed by others), in predicting psychotic-like experiences (PLEs) six months later in a general population sample (N = 314). It also tested if social safeness moderates these effects. A longitudinal, online questionnaire design tested a moderation model (dissociation-shame) and a moderated moderation model (adding social safeness), using multiple regressions with bootstrap procedures. RESULTS: Although there was no direct effect of dissociation on PLEs six months later, there was a significant interaction effect with shame, controlling for PLEs at baseline. There were complex patterns in the directions of effects: For high-shame-scorers, higher dissociation predicted higher PLE scores, but for low-shame-scorers, higher dissociation predicted lower PLE scores. Social safeness was found to significantly moderate these interaction effects, which were unexpectedly more pronounced in the context of higher social safeness. CONCLUSIONS: The results demonstrate evidence for an interaction between dissociation and shame on its impact on PLEs, which manifests particularly for those experiencing higher social safeness. This suggests a potential role of social mechanisms in both the etiology and treatment of psychosis, which warrants further testing in clinical populations.

Investigating associations between self-compassion, self-criticism and psychotic-like experiences.

OBJECTIVES: Dimensional approaches suggest psychotic symptoms exist along a continuum, with psychotic-like experiences (PLEs) being an expression of a non-clinical psychosis phenotype. Existing research indicates self-criticism may contribute to symptom maintenance, frequency and distress, whereas self-compassion may act protectively. Associations between self-criticism, self-compassion and PLEs in the general population have received less attention. The present study sought to investigate these associations. It was hypothesised that PLE endorsement would be associated positively with self-criticism and negatively with self-compassion. DESIGN: Quantitative cross-sectional study. Data collected via an online questionnaire. METHODS: Five hundred thirty-one participants completed the Self-Compassion Scale (Short Form), the Forms of Self-Criticising/Attacking and Self-Reassuring Scale and the Transpersonal Experiences Questionnaire. Individuals with a psychosis-related diagnosis were excluded. The data were analysed using linear regression, accounting for the effects of demographic variables. RESULTS: Self-criticism subtype self-hatred was associated with PLEs. Subtype self-inadequacy was not. No association was found between self-compassion and PLEs. Educational attainment was negatively associated with PLE endorsement. CONCLUSIONS: Self-criticism, but not self-compassion, is associated with PLE endorsement, suggesting they are separate factors with different relationships to PLEs. Further research is needed to confirm the direction of the interaction. Either way, psychological interventions (where needed) could target self-criticism and may be important in assessing psychosis risk.

Position paper - CFT for psychosis.

PURPOSE: This paper outlines the theoretical and empirical basis for compassion focused therapy (CFT) for psychosis, the gaps in the current knowledge and research, as well as some of the challenges for addressing gaps. It will guide the direction of future work and the steps needed to develop and advance this approach. METHOD: This paper reviews evidence of how evolutionary models such as social rank theory and attachment theory have greatly contributed to our understanding of psychosis and provide a clear rationale and evidence base for the mechanisms of change in CFT for psychosis. It reviews the evidence for outcomes of compassion training more generally, and early feasibility evaluations of CFT for psychosis. RESULTS: The process evidence shows that people with psychosis have highly active social rank and threat systems, and the benefits of switching into attachment and care systems, which can support emotion regulation and integrative mind states. The outcomes evidence shows that compassion training impacts not only psychological outcomes, but also physiological outcomes such as neural circuits, immune system, and the autonomic nervous system. Within the psychosis field, outcomes research is still in the early days, but there are good indications of feasibility and a clear path forward for the next steps. CONCLUSIONS: CFT for psychosis is an approach that integrates biopsychosocial processes, an integration that's evidenced across each aspect of the model, from theoretical foundations (evolution-informed) to interventions (e.g., body/breath training and relational techniques), to evaluation. Future RCTs are required to understand the effects on biopsychosocial outcomes for people with psychosis.

A case series study of compassion-focused therapy for distressing experiences in psychosis.

OBJECTIVES: Compassion-focused therapy (CFT) is an evolution-informed biopsychosocial approach that seeks to cultivate attachment and care motivational systems and their psychophysiological regulators. These can counteract some of the harmful effects of social threat, inferiority, shame, self-criticism and depression, which are common in people with psychosis and undermine their well-being, social trust and ability to feel safe. This study aimed to test the acceptability of a novel manualized individual CFT intervention for psychosis (CFTp). DESIGN: A non-concurrent, multiple-baseline, case series design, with three phases: baseline, intervention and follow-up. METHODS: The 26-session CFTp intervention was provided for a sample of eight people with distressing psychotic experiences and a psychosis-related diagnosis. The study aimed to assess acceptability of CFTp and to test clinically reliable improvements while receiving the intervention, compared to a baseline period. RESULTS: Seven of eight participants completed the therapy, and clinically reliable improvements were found at both the single-case and group level of analysis. At the single-case level, over half the participants showed improvements in depression (5/7), stress (5/7), distress (5/7), anxiety (4/7) and voices (3/5). One participant showed a deterioration in anxiety (1/7) and dissociation (1/7). At the group level (n = 7), there were significant improvements in depression, stress, distress, voices and delusions. The improvements in voices, delusions and distress were sustained at 6- to 8-week follow-up, but depression and stress dropped slightly to trend-level improvements. CONCLUSIONS: CFTp is a feasible and acceptable intervention for psychosis, and further investigation is warranted with a randomized controlled trial.

Detecting anomalous experiences in the community: The Transpersonal Experiences Questionnaire (TEQ).

OBJECTIVES: There is growing recognition of the value of researching anomalous experiences in the general population to aid our understanding of the psychosis continuum. There are key differences in aims, foci and epistemologies of existing measures, with varying utility for specific research designs. This study addresses gaps in the literature by developing a measure of anomalous experiences with utility for longitudinal (time-sensitive) research, and with particular reliability for people towards the upper (high scoring) end of the continuum. METHODS: An online sample was recruited from the general population to provide questionnaire data for two study parts: (A) item selection and (B) psychometric evaluation. For Part A, both classical test theory and item response theory methods were used to select which items to be included from an initial pool of 57, generated from individuals with persistent anomalous experiences. For Part B, psychometric properties of the resulting measure were evaluated using exploratory and confirmatory factor analysis and tests of reliability and validity. RESULTS: Scores were provided by 532 participants, from which a 19-item scale, the Transpersonal Experiences Questionnaire (TEQ), was developed. The TEQ was found to be a unidimensional scale, with satisfactory internal consistency (0.85), good test-retest reliability and convergent validity. CONCLUSIONS: The TEQ can be used as a unidimensional scale to detect anomalous experiences in the general population, with particular reliability for people with higher incidence of these experiences.

A case report of compassion-focused therapy for distressing voice-hearing experiences.

This paper describes a 6-month period of compassion-focused therapy (CFT) for a client who has a 35-year history of hearing voices that are threatening, derogatory, and abusive. In this intervention, the client is encouraged to develop compassionate motives toward herself and to her voices, recognizing that her voices may have been functional in the context of difficult early experiences. The client develops a compassionate self-identity, which becomes the vehicle through which she approaches therapeutic tasks, such as listening and talking to voices, engaging with traumatic childhood pain, and resolving emotional conflicts. The client is an author on this study, so is able to provide valuable first-hand insights into the experience of working compassionately with her voices, and of experiencing CFT techniques for the first time.

Trauma and Social Pathways to Psychosis, and Where the Two Paths Meet.

The pathways from trauma-via dissociation-to psychosis have been thoroughly tested and evidenced, but what has received less attention has been the social pathways-via dissociation-to psychosis. Often social factors are more commonly linked to other influences, e.g., to appraisals and the creation of negative schema in cognitive models, or to unsupportive caregiving experiences where there is high "expressed emotion." However, evidence is now emerging that negative social rank experiences, such as being excluded or shamed, may themselves have dissociative properties, which poses intriguing questions as to how trauma pathways and social pathways might interact. This article reviews the state of knowledge in trauma and social pathways to psychosis and then considers the potential mechanisms and the relationships between them, specifically (i) dissociation, (ii) attachment, and (iii) social rank. Recommendations are suggested for future modeling and testing of three-way interactions (dissociation × attachment × social rank) in the pathway from trauma to psychosis.

Compassionate Mind Training: An 8-week group for the general public.

OBJECTIVES: There is an increasing interest in how compassion training, and in particular, the cultivation of self-compassion may be an important component in the reduction of distress and promotion of well-being. Compassion Focused Therapy (CFT) has shown promising results in this area, with positive outcome studies in a wide range of mental health problems. However, following the successful development of short mindfulness-based programmes (e.g., Mindfulness-based Stress Reduction and Mindfulness-based Cognitive Therapy) and compassion/self-compassion programmes (e.g., Mindful Self-Compassion) that can be accessed by the general public, we were keen to develop and research an 8-week Compassionate Mind Training (CMT) course, based on the CFT model. DESIGN: Within-subjects pre-to-post-group comparison. METHODS: Following an 8-week CMT groups, participants in the general population (n = 55) completed pre- and post-measures (with 22 of these also providing 3-month follow-up data) on self-compassion, compassion for others, compassion from others, attachment, self-criticism, positive emotion, well-being, and distress. RESULTS: Significant increases in compassion, self-reassurance, social rank, positive emotions, and well-being were found, alongside reductions in self-criticism, attachment anxiety, and distress. Changes were maintained at 3-month follow-up. Change scores indicated the importance of increases in self-compassion and reductions in self-criticism in overall improvements in well-being and psychological distress. CONCLUSIONS: Findings offer preliminary support for the usefulness of group CMT in community samples. PRACTITIONER POINTS: Compassionate Mind Training (CMT) groups appear to be applicable and beneficial in community samples. CMT psychoeducation and practices appear to bring positive changes to a variety of psychological processes, including attachment, self-criticism, self-compassion, well-being, and distress. Further studies are required to investigate whether the mechanisms through which CMT is beneficial.

Compassion Focused Approaches to Working With Distressing Voices.

This paper presents an outline of voice-hearing phenomenology in the context of evolutionary mechanisms for self- and social- monitoring. Special attention is given to evolved systems for monitoring dominant-subordinate social roles and relationships. These provide information relating to the interpersonal motivation of others, such as neutral, friendly or hostile, and thus the interpersonal threat, versus safe, social location. Individuals who perceive themselves as subordinate and dominants as hostile are highly vigilant to down-rank threat and use submissive displays and social spacing as basic defenses. We suggest these defense mechanisms are especially attuned in some individuals with voices, in which this fearful-subordinate - hostile-dominant relationship is played out. Given the evolved motivational system in which voice-hearers can be trapped, one therapeutic solution is to help them switch into different motivational systems, particularly those linked to social caring and support, rather than hostile competition. Compassion focused therapy (CFT) seeks to produce such motivational shifts. Compassion focused therapy aims to help voice-hearers, (i) notice their threat-based (dominant-subordinate) motivational systems when they arise, (ii) understand their function in the context of their lives, and (iii) shift into different motivational patterns that are orientated around safeness and compassion. Voice-hearers are supported to engage with biopsychosocial components of compassionate mind training, which are briefly summarized, and to cultivate an embodied sense of a compassionate self-identity. They are invited to consider, and practice, how they might wish to relate to themselves, their voices, and other people, from the position of their compassionate self. This paper proposes, in line with the broader science of compassion and CFT, that repeated practice of creating internal patterns of safeness and compassion can provide an optimum biopsychosocial environment for affect-regulation, emotional conflict-resolution, and therapeutic change. Examples of specific therapeutic techniques, such as chair-work and talking with voices, are described to illustrate how these might be incorporated in one-to-one sessions of CFT.

Tackling Social Cognition in Schizophrenia: A Randomized Feasibility Trial.

BACKGROUND: Social cognition difficulties in schizophrenia are seen as a barrier to recovery. Intervention tackling problems in this domain have the potential to facilitate functioning and recovery. Social Cognition and Interaction Training (SCIT) is a manual-based psychological therapy designed to improve social functioning in schizophrenia. AIMS: The aim of this study is to evaluate the feasibility and acceptability of a modified version of SCIT for inpatient forensic wards. The potential benefits of the intervention were also assessed. METHOD: This study is a randomized single blind controlled design, with participants randomized to receive SCIT (N = 21) or treatment as usual (TAU; N = 15). SCIT consisted of 8-week therapy sessions twice per week. Participants were assessed at week 0 and one week after the intervention on measures of social cognition. Feasibility was assessed through group attendance and attrition. Participant acceptability and outcome was evaluated through post-group satisfaction and achievement of social goals. RESULTS: The intervention was well received by all participants and the majority reported their confidence improved. The SCIT group showed a significant improvement in facial affect recognition compared to TAU. Almost all participants agreed they had achieved their social goal as a result of the intervention. CONCLUSIONS: It is feasible to deliver SCIT in a forensic ward setting; however, some adaptation to the protocol may need to be considered in order to accommodate for the reduced social contact within forensic wards. Practice of social cognition skills in real life may be necessary to achieve benefits to theory of mind and attributional style.

A compassionate-focused therapy group approach for acute inpatients: feasibility, initial pilot outcome data, and recommendations.

OBJECTIVES: This study aimed to examine the feasibility of running and evaluating a compassion-focused therapy (CFT) group adapted for acute inpatient settings, characterized by unpredictable lengths of admission, presentations, and diagnoses. DESIGN AND METHODS: This pilot project used a mixed methods design to assess the impact of offering CFT-informed group sessions on an acute inpatient unit. Pre- and post-session ratings of distress and calmness, and ratings of understanding and helpfulness, were gathered from participants over a 6-month period. Semi-structured interviews were conducted with four participants to gather their experience of the group. RESULTS: Fifty-seven complete sets of rating measures were generated from 82 participants recruited for the study (attrition rate 30%), from a total pool of 93 inpatients attending group sessions. Pre- to post-CFT session data highlighted a significant decrease in distress ratings and a significant increase in calmness ratings. A thematic analysis of four interviews identified themes relating to understanding compassion, experience of positive affect, and the experience of common humanity. CONCLUSIONS: This is the first attempt to explore the effects of a CFT-informed approach in acute mental health settings. These groups were well received by staff and patients, with some therapeutic impact despite being comparatively short and set against the background of a busy inpatient ward. These groups can be open and transdiagnostic, with stand-alone topics and practices having positive impacts on distress and calmness. Future studies need to focus on adapting content and pacing for this group of people based on ongoing feedback from participants.

Predictors of distress associated with psychotic-like anomalous experiences in clinical and non-clinical populations.

OBJECTIVES: Psychotic-like anomalous experiences are not inherently distressing, nor do they inevitably lead to clinical conditions. However, distress is an important predictor of onset and relapse in psychosis, and a primary indicator of problematic mental health. This study aimed to identify factors that predict distress across three groups with anomalous experiences. DESIGN AND METHODS: This study used a cross-sectional design. Participants in 'Diagnosed' (n = 35), 'At Risk' (n = 20), and 'Undiagnosed' (n = 36) groups completed the Appraisals of Anomalous Experiences Interview (AANEX; Brett et al., 2007, Br. J. Psychiatry, 191, s23), which taps anomalies experienced, appraisals, and other psychological and contextual variables. A series of ordinal logistic regression analyses was conducted to investigate which variables predicted anomaly-related distress. RESULTS: Predictors of higher distress were anomalous states characterized by changes in awareness and cognitive functioning (rather than more typical positive symptoms), appraisals of experiences as caused by 'other people', and greater attempted control over experiences. Predictors of lower distress were 'spiritual' appraisals, greater perceived social support/understanding, greater perceived controllability, and reacting with a 'neutral response'. CONCLUSIONS: While psychotic-like experiences themselves are not necessarily distressing, appraisals and responses to anomalies do predict distress, as do factors relating to the social context. This adds support to the cognitive-behavioural models, and continuum models, of positive psychotic symptoms.

A qualitative comparison of psychotic-like phenomena in clinical and non-clinical populations.

OBJECTIVES: To explore the nature and context of psychotic-like phenomena in clinical (C) and non-clinical (NC) participants, and to investigate whether the factors involved with triggering a psychotic-like 'out-of-the-ordinary' experience (OOE) can be distinguished from those determining its clinical consequences. DESIGN AND METHODS: Qualitative data were collected by semi-structured interviews, and analysed using interpretative phenomenological analysis (IPA). Twelve participants, who reported OOEs starting in the last 5 years, were split into C and NC groups depending on whether they were involved with mental-health services as a result of their experiences. Inter-group comparisons of emergent themes were made. RESULTS: Inter-group similarities were found in the triggers and subjective nature of experiences, with clearer group differences in the inter-personal and background personal contexts, and how the experiences were incorporated into their lives. In particular, the inter-personal theme of validation was identified as important in distinguishing the clinical consequences of OOEs. CONCLUSIONS: It is not the OOE itself that determines the development of a clinical condition, but rather the wider personal and interpersonal contexts that influence how this experience is subsequently integrated. Theoretical implications for the refinement of psychosis models are outlined, and clinical implications for the validation and normalization of psychotic-like phenomena are proposed.