LOSS OF SELF IN PSYCHOSIS In Loss of Self in Psychosis: Psychological Theory and Practice Simon Jakes takes a critical look at contemporary approaches to the psychology of psychosis. In doing so, he explores how these vastly different approaches, as well as our numerous conceptual- isations of schizophrenia, work to reduce the effectiveness of CBT as a treatment. Four different psychological approaches to psychosis are examined in the first part of this book, as well as the development of CBT for psychosis and the theory behind this. In the second part, he describes the therapy of some clients and suggests that incorporating ideas from some of the different theories of psychosis in the same treatment may be beneficial. Using extended examples from clinical practice over the past 20 years to illuminate his theories, Loss of Self in Psychosis: Psychological Theory and Practice will prove to be thought-provoking reading for clinical psychologists, psychiatrists and other mental health professionals working with this client group. Simon Jakes is a clinical psychologist at the Bankstown Community Mental Health Team in South Western Sydney, New South Wales. He is also in private practice. LOSS OF SELF IN PSYCHOSIS Psychological Theory and Practice Simon Jakes First published 2018 by Routledge 2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN and by Routledge 711 Third Avenue, New York, NY 10017 Routledge is an imprint of the Taylor & Francis Group, an informa business © 2018 Simon Jakes The right of Simon Jakes to be identified as author of this work has been asserted by him in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data Names: Jakes, Simon, 1956- author. Title: Loss of self in psychosis : psychological theory and practice / Simon Jakes. Description: Milton Park, Abingdon, Oxon ; New York, NY : Routledge, 2018. | Includes bibliographical references. Identifiers: LCCN 2017056921| ISBN 9781138680128 (hbk) | ISBN 9781138680135 (pbk) | ISBN 9781351213622 (ebk) | ISBN 9781315523996 (epub) | ISBN 9781315524016 (master) | ISBN 9781315524009 (web) | ISBN 9781315523989 (mobipocket) Subjects: LCSH: Psychoses—Treatment. Classification: LCC RC512 .J28 2018 | DDC 616.89—dc23 LC record available at https://lccn.loc.gov/2017056921 ISBN: 978-1-138-68012-8 (hbk) ISBN: 978-1-138-68013-5 (pbk) ISBN: 978-1-315-52401-6 (ebk) Typeset in Bembo by Keystroke, Neville Lodge, Tettenhall, Wolverhampton To Ian CONTENTS Preface ix Acknowledgements xi PART ONE 1 1 Introduction 3 2 Cognitive-behavioural therapy for psychosis (CBTp) 7 3 Normalisation 25 4 Cognitive neuropsychology of “schizophrenia” 42 5 Philosophical psychology 55 6 Psychoanalysis 77 PART TWO 109 7 Applications 111 References 130 Index 135 PREFACE In 1975 I went to work in Claybury Hospital in Woodford Green, Essex. At that time deinstitutionalisation was yet to become a government policy. I was assigned to work on a “back ward”. The people on the ward had been there for many years. The patients had been there for many years and the staff had been there for many years. The charge nurse on the ward was approaching retirement. The charge nurse used to lock the doors at the time that the shift started, so if one was a couple of minutes late one could not get on the ward. We wore white coats and served up the client’s food. We then sat around, as there was nothing to do. He and the other nurses would reminisce about the good old days prior to anti-psychotic medication when patients would have to be restrained by being forced back with unattached doors. The clients sat around with nothing to do either, chairs pushed against the walls, interacting with no one. One man used to put together skipping ropes, and then undo them and then reassemble them. This was a leftover from when there used to be an “industrial therapy unit” in which patients had been employed, and he was the most active in his rather pathetic attempts to keep busy. And I rather naively thought that there must be a real medical need for these people to be kept for years in the hospital. I should have looked into the history of the hospital. I knew that it had once been called “Claybury Lunatic Asylum”, but I thought that was just outdated language, rather than being nearer to the truth. Claybury was one of the London County Council commissioned asylums for pauper lunatics. And the “pauper” gives the function away. Prior to the asylums, pauper lunatics had been housed in the workhouse, and the function of the asylum continued rather the same: providing food and shelter at an economic rate for the taxpayer and deterring anyone who could maintain themselves from asking for poor relief. This was living history. What had once been the way that all paupers were treated was now reserved only for the mad. x Preface This double-speak about care and control is endemic in psychiatry. Anyway this was the first lesson I had in the care of people with psychosis. The asylums are largely gone (and a fair amount of care in the community has gone with them, at least if Sydney is anything to go by). The dual function of mental health services to treat and to control is, however, still there, and this practical and political issue still runs through the philosophy of treatment. Theories get put to practical purposes. The theory of mental illnesses can be used to help people or it can be used to keep people in institutions for years. You have to watch out for theory. ACKNOWLEDGEMENTS I would like to thank John Rhodes, Hazel Nelson, Paul Chadwick, Dallas Rae, Renate Wagner and Dick Hallam, who all helped in various ways with the ideas in this book and are not responsible for any of the errors, and the clients who allowed their stories to be told. Without the editorial team at Routledge the book would never have been written, so thanks to Joanne Forshaw, Charlotte Taylor and Katie Hemmings, and to Sarah Sibley for her very helpful work in putting order into my slightly chaotic manuscript. I would additionally like to thank Springer-Verlag for permission to publish excerpts from Karl Jasper’s “General Psychopathology”. Also Soraya, Ben, Joseph, Sam and Luke, who contributed considerably to the delay in finishing the book. And, of course, my parents. PART ONE 1 INTRODUCTION Feyerabend (1963), the philosopher of science, wrote: Schizophrenics very often hold beliefs which are rigid, all-pervasive, and unconnected with reality, as are the best dogmatic philosophies. Only such beliefs come to them naturally whereas a professor may sometimes spend his whole life in attempting to find arguments which create a similar state of mind . Unanimity of opinion may be fitting for a church, for the frightened victims of some (ancient or modern) myth, or for the weak and willing followers of some tyrant; variety of opinion is a feature necessary for objective knowledge . and . a humanitarian outlook. He meant this as a comment on dogmatic scientific theories rather than on “schizophrenics”, although some contemporary authors would argue that the delusions of people with psychosis are essentially dogmatic philosophies. But Feyerabend’s comments are of relevance to us in another way. In an area such as psychosis, workers or clinicians in one field often operate without reference or knowledge of the models being used by workers in other fields. So the psychologist exploring an information-processing model of psychosis will sometimes know nothing of the models being used in therapy. Clinicians are often advised to formulate the clients’ problems and relate them to a particular theory. But if the theories cannot claim to be a comprehensive explanation, then this, I will suggest, is dogmatism rather that empiricism. Feyerabend suggested that there is no one scientific method and that scientists have broken all the supposed rules of method. And we should use whatever method works. Part of the goal of writing this book is to bring together disparate psychological accounts of psychosis for the practising or aspiring clinician, because, I will suggest, as we don’t have an explanation of psychosis or schizophrenia, that as empiricists we should draw from different theories when they are useful. 4 Part one In this book I review some quite different approaches to the psychology of psychosis. Not only are the models quite varied, but the way of describing the problem is also varied, reflecting different points of view. So, for example, some talk of “schizophrenia”, whereas others talk of “psychosis”. This can make it difficult to know what we are talking about or whether we are talking about the same thing. So, for example, if we eschew the term “schizophrenia” as an unreliable and invalid term, possibly a fiction, certainly stigmatising, and possibly a conspiracy, we are left talking of “psychosis”, but the problem here is that this is a very wide term. Becoming psychotic in the midst of a deep depression may or may not be the same as becoming psychotic after a long gradual withdrawal from the world, or becoming psychotic in an emotional crisis.