Telling Stories?: Attachment-Based Approaches to the Treatment of Psychosis

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Telling Stories? explores the contemporary state of affairs in the understanding and treatment of psychosis. An inclusive approach to mental distress requires that in order to truly understand psychosis we must begin by listening to those who know this from the inside out; the voices and narrative of those who have been condemned as "unanalysable" and mad. Far from being fantastical, the complex stories that are being articulated communicate painful truths and the myriad ways in which the human psyche survives overwhelming trauma. This book is the culmination of an integrated and creative alliance between those on the cutting edge, experientially, in research, diagnosis, and treatment; this multidisciplinary dialogue proposes a new relational and attachment orientated paradigm for the 21st century. In contrast to the containment model that is currently favoured, this advocates listening and talking therapies, and the healing power of a loving relationship, offering those with psychosis the possibility of more nourishing engagement with the world.

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Chapter One: Telling stories? Attachment-based approaches to the treatment of psychosis

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Sarah Benamer

Why “Telling Stories?”? Because these are the stories denied throughout history, dismissed as fantasy or lies. These are the stories that tell us much about the nature of mental distress, and about the resourceful ways in which the human body and mind process and remember overwhelming trauma. These are the stories that mean that it is no longer possible to dehumanize “the other”. These are the stories that tell us of ourselves.

People deemed psychotic have been marginalized in society; their expression of internal terror is itself experienced as terrifying and is managed as a public health issue, historically by incarceration and restraint and more recently with medication. This defensive, fear-based reaction has left little scope for exploration and creativity in the field, with many questions remaining unanswered and the actual experiences of those with psychosis remaining, with a few notable exceptions, almost exclusively unheard.

Contextualizing psychosis in the light of real world experience enables an awareness of “madness” as an adaptive response which employs whatever means to maintain attachment to significant others and ensure that persons survival. This adaptation can echo both individual circumstance and the wider social structure, explaining trends such as the over-representation of certain groups including women, and the black and Irish communities, in the diagnostic statistics as a reflection of patriarchy or the post-colonial experience and racism. By appreciating an individual’s psychotic story within a relational attachment framework it is possible to see how they understand themselves, their developmental journey, personal experience of trauma, and how this influences current patterns of behaviour. The narrative of psychosis engages all aspects of a person’s being and as individual stories are told we come to understand how the body is employed in non-verbal psychotic communication.

 

Chapter Two: A brief history of psychosis, its politics and why genetics is a cop-out

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Joseph Schwartz

We are speaking of mental states and behaviours that seem incomprehensible. They are that way because of the unbearable mental pain endured by the sufferers of what was called madness. Telling stories? Who is there with the courage to listen? Barbro Sandin, a national hero in Sweden for her successful treatment of what is called schizophrenia, said: “With all my might I wanted to fight for the restoration and renewal of at least one of these forgotten persons”(2009).

Historically, the listeners have been few and far between. In 1811 consignment to madhouses was seen as a death sentence: “His friends judged rightly: to have him committed to a madhouse would have in all probability fixed him irremedial madness” (taken from A Report on Madhouses in England, 1811, Porter, 1987, p. 352). The 19th century reformers John Connolly and Henry Maudsley tried to de-demonize madness. The extremities of mental pain became a medical problem. By the end of the century the treatments were wide and varied. In Studies on Hysteria, Breuer and Freud reported: “Treatment of the usual kind was ordered: the electric brush, alkaline water, purges; but each time the neuralgia remained unaffected until it chose to give place to another symptom. Earlier in her life—the neuralgia was fifteen years old—her teeth were accused of being responsible for it. They were condemned to extraction, and one fine day the sentence was carried out on seven of the criminals” (1895, p. 249).

 

Chapter Three: Never let the truth get in the way of a good story

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Julie McNamara

I was born in the middle of a rebellion. That’s how I see it. My father was Catholic, my mother a Protestant, and in the part of Ireland they hailed from it was not the done thing to be seen talking to each other, let alone running away to breed five children out of wedlock. You could say they were rebels of their time. Ahead of their time they were. They moved house swiftly and often, to avoid the scorn of neighbours and constant disapproval snapping at their heels.

They made it to Liverpool where most Irish blow-ins came looking for a new world in this country and where Father Brannigan made it his mission to get these two wed. He was determined to have them blessed in church. But to do so he had to persuade my mother to become a Catholic. Well you have not met my mother. She is sharp of tongue and wit and a fine role model to boot. He took her to one side and taught her the ways of the faith. Oh, there may be those among you who know little of the Catholic faith. Well, there are two levels of sin: mortal and venial (or in our family’s case, moral and venereal).

 

Chapter Four: The personal is political

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Jacqui Dillon

The concept of the personal is political developed out of the women’s liberation movement in the 1960s (Hanish, 1969). It was an acknowledgment that the experiences, feelings, and possibilities of our personal lives are not just a matter of personal preferences and choices but are limited, moulded, and defined by the broader political and social setting. They feel personal, and their details are personal, but their broad texture and character, and especially the limits within which these evolve, are largely systemic. This concept is very relevant to contemporary mental health too but before looking at the political I would like to start with the personal. I would like to go back, right to the very beginning.

This is a picture of me aged five on the street in Hackney in east London where I grew up. I was already hearing voices by then. My early years were filled with many terrifying and disturbing experiences that literally shattered me into pieces. My family was involved with a group of organized, sadistic paedophiles, who abused children and took part in extreme sado-masochistic practices. The consequence of such extreme and sustained abuse is devastating. Its effects are all-consuming, encompassing every aspect of experience. To be betrayed and exploited by those who are meant to protect you leaves a profound sense of terror, isolation, and shame.

 

Chapter Five: Can attachment theory help explain the relationship between childhood adversity and psychosis?

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John Read and Andrew Gumley

For several decades our efforts to understand the causes of human distress, despair, and confusion have been impeded by the dominance of a simplistic, reductionist paradigm interested primarily or exclusively in genes and neurotransmitters (Bentall, 2003; Read, Mosher & Bentall, 2004). This “medical model” has been enthusiastically supported by the pharmaceutical industry, which has much to gain from promulgating an ideology that minimizes psycho-social causes (Mosher, Gosden & Beder, 2004; Read, 2008). Although the dominance of this model pervades all categories of psychiatric diagnoses, nowhere has it been stronger or more damaging than in the field of psychosis. Since the invention of the supposed illness “schizophrenia” a century ago (Bentall, 2003; Read, 2004a), millions of people worldwide have been condemned to the pessimistic, self-fulfilling, and stigmatizing belief that they are suffering from some kind of irreversible brain disease. This disease, which has wrongly been presented as largely genetically determined, supposedly has little or nothing to do with one’s life history or circumstances.

 

Chapter Six: Truth is stranger than fiction—what happens to the story when no-one wants to know

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Christine Blake

A woman lies in her gorgeous lover’s arms. Her lover is using her hands to cast shadows on the wall, making angry glances and muttering under her breath. She appears to be talking to someone from time to time, but no-one else is there. Nothing her lover has said over the last three days has seemed to make much sense. The woman has done her best to relate—to connect—to her lover for whom she feels deeply, now laying by her side in her own separate world. Concerned for her lover she is also strung out herself, exhausted and dimly aware of feeling a little shaky about her own sense of self—no longer sure of her own grip on what she usually perceives as reality. After all she has not spoken to anyone except her lover over the last few days and has attempted to relate to her lover on her lover’s own terms since nothing else has appeared to work. Watching her lover make these ominous-seeming shapes against the wall, cold and unresponsive to dialogue now—the woman wonders if her lover will kill her in the night. Lying there feeling wiped out she decides she is too tired to care. She reasons to herself she will soon know if she is still alive in the morning and falls fast asleep.

 

Chapter Seven: In bits: Hearing the fragmented narratives of people who experience psychosis

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Mark Linington

In 1913, Freud (p. 153) wrote: “I recollected how often wrong views were taken about psychotic patients simply because they had not been studied enough and had not told enough about themselves.” However, in the continuing development of our relational understanding of “psychotic patients,” it may be insufficient merely to study people’s experiences and give them opportunities to tell their stories. We will need also to include reflections upon what happens to us, as clinicians, when we are involved with people and their psychotic narratives.

As Harold Searles (1979, p. 286) puts it: “One must become able to experience within oneself, in manageable increments, the intense and discoordinate emotions the patient is having to unconsciously to defend against with his craziness. This process provides the necessary therapeutic context for the patient’s coming to explore and understand the meanings of his psychosis.”

My experience, as an attachment-based psychoanalytic psychotherapist, is with people with learning disabilities, who experience psychosis. I work with psychosis as a severe enactment crisis—often responded to with medication and hospitalization—as well as with psychosis as an ongoing internal and relational interference. We are beginning to understand that such psychotic problems, in both their crisis form and in their enduring confusion of inside and outside, have their origin in early severe interpersonal trauma, occurring within chronically insecure attachment-caregiving relationships (Read et al., 2005), which are themselves manifestations of intergen-erational traumas and broader social experiences.

 

Chapter Eight: Interprofessional collaboration: Achieving integrated care in mental health services

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Tony Leiba

Interprofessional collaboration and working between psychotherapy and the statutory services in mental health is essential if service users and their carers are to receive a seamless service. Interprofessional collaboration and working is a highly complex activity. Some of the challenges for the statutory services in mental health and psychotherapists in working together are evident in ideological differences, power and status relationships, differing organizational cultures, and disparity of professional language.

This chapter will present some introductory thoughts on interprofessional collaboration, along with some discussion of the relevant advantages and challenges. The stimulus for this paper grew out of The Bowlby Centre Conference (2008), “Telling Stories? Attachment-based Approaches to the Treatment of Psychosis”. During the discussion sessions at the conference, it became clear that the health professionals from the statutory services for people deemed to be undergoing a psychotic experience, and psychotherapists involved in the care of these individuals, often struggled to find a common paradigm and language to enable service users to receive effective care.

 

Appendix

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Noble, E.P. & Blum, K. (1991). The dopamine D2 receptor gene and alcoholism. JAMA, 265: 2667.

MacDonald, K. (1998). Towards an Evolutionary Theory of Anti-Semitism. New York: Praeger.

Lesch, K.P., Bengel, D., Heils, A., Sabol, S.Z., Greenberg, B.D., Petri, S., Benjamin, J., Müller, C.R., Hamer, D.H. & Murphy, D.L. (1996). Association of anxiety-related traits with a polymorphism in the serotonin transporter gene regulatory region. Science, 274: 1527–1531, 1483.

Science Random Samples (1997). A gene is linked to autism. Science, 276: 905.

Science News Focus (2001). New hints into the biological basis of autism. Science, 294: 34–37.

Egleland, J.A., Gerhard, D.S., Pauls, D.L., et al. (1987). Bipolar affective disorder linked to chromosome markers on chromosome 11. Nature, 325: 783–877.

Entine, J. (2000). Taboo: Why Black Athletes Dominate Sports and Why We’re Afraid to Talk About It. New York: Public Affairs.

Science News and Comment (1994). Violence tudy hits a nerve in Germany. Science, 264: 653.

 

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