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2020 Heriot-Maitland Charles 1276898 Ethesis This electronic thesis or dissertation has been downloaded from the King’s Research Portal at https://kclpure.kcl.ac.uk/portal/ Social influences on dissociative processes in psychosis Heriot-Maitland, Charlie Awarding institution: King's College London The copyright of this thesis rests with the author and no quotation from it or information derived from it may be published without proper acknowledgement. END USER LICENCE AGREEMENT Unless another licence is stated on the immediately following page this work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International licence. https://creativecommons.org/licenses/by-nc-nd/4.0/ You are free to copy, distribute and transmit the work Under the following conditions: Attribution: You must attribute the work in the manner specified by the author (but not in any way that suggests that they endorse you or your use of the work). Non Commercial: You may not use this work for commercial purposes. No Derivative Works - You may not alter, transform, or build upon this work. Any of these conditions can be waived if you receive permission from the author. Your fair dealings and other rights are in no way affected by the above. Take down policy If you believe that this document breaches copyright please contact [email protected] providing details, and we will remove access to the work immediately and investigate your claim. Download date: 07. Oct. 2021 Social influences on dissociative processes in psychosis Charles Heriot-Maitland Department of Psychology Institute of Psychiatry, Psychology & Neuroscience King’s College London This thesis is submitted to the University of London for the degree of Doctor of Philosophy. 2019 Abstract Previous research has investigated socially based threats, such stigmatisation and shame, among people with psychosis. However, studies have typically considered these social experiences in terms of being the consequences, rather than causes, of psychosis. There have been some studies looking at stigma and shame as causal mechanisms in emotional symptoms (e.g. anxiety and depression) in the context of psychosis, and of post-psychotic trauma, but not of psychosis itself. One possible reason for why this may have been overlooked is that stigma and shame have not traditionally been regarded in ‘threat’ terms, with traumatic-like, perhaps dissociative, properties of their own. Social rank theory (Gilbert, 1992) offers an understanding of these socially-based experiences within their evolutionary context, with links to developing threat-monitoring, -processing, and -protective strategies. Social rank theory therefore provides a theoretical rationale within which to examine stigma and shame through the lens of threat and threat-protection mechanisms. These social rank threats can be investigated for links to traumatic, dissociative processes, and hence as potential contributors to causal pathways in psychosis. This thesis investigates the interaction of these social and dissociative processes in psychosis (Section A: Studies 1, 2, and 3). It also develops and tests the acceptability of a new psychological therapy that specifically targets social mechanisms, e.g. reducing shame and increasing social safeness, among people with psychosis (Section B: Study 4). The first study designed and tested a measure of psychotic-like experiences (PLEs) that could be used for the other studies. Study 1, a questionnaire design study, analysed data from online participants for a) item selection, and b) psychometric evaluation. Scores were provided by 532 participants, and a new scale, the Transpersonal Experiences Questionnaire (TEQ), was developed. The 19-item TEQ was found to be a unidimensional scale with satisfactory internal consistency (0.85), good utility for longitudinal hypothesis-testing, and particular reliability for people endorsing a high number of PLE items. Study 2 investigated the longitudinal relationship between dissociation and PLEs, and the moderation effects of social variables, shame and social safeness, on this relationship. Participants (n=314) provided online data at two timepoints (0 and 6 months) and the analysis demonstrated a significant interaction between dissociation and shame on PLEs, despite the absence of a direct association between dissociation and PLEs. Social safeness significantly moderated this interaction effect, but not in the expected direction: higher social safeness was associated with more pronounced dissociation-shame interaction effects. In Study 3, participants (n=30) were recruited from a ‘non- clinical-in-crisis’ population; i.e. those seeking support for PLEs, but from spiritual organisations rather than mainstream services. This sample had significant trauma histories and high levels of dissociation. 2 Endorsing a higher number of PLE items was related to more distress; however, once total endorsement scores were controlled for, PLEs were rated as more positive (‘enriching’, ‘safe’ and ‘pleasant’) than negative (‘distressing’ and ‘disruptive’). The positive PLE dimensions were correlated with spirituality, post-experience growth, and social safeness. Negative PLE dimensions were correlated with depression. The second section of the thesis reports the development and initial piloting of a new clinical intervention called Compassion Focused Therapy for Psychosis (CFTp). CFTp specifically targets building social safeness experience and compassion motivation systems with the aim of regulating threat-based dissociative processes in psychosis. Study 4 was a case series study, in which NHS participants with distressing experiences were randomised to multiple baseline periods of 2, 4 and 6 weeks, before a 26-session individual therapy. Seven out of eight participants completed the full 26 sessions. At the single case level of analysis, over half the completers showed clinically reliable improvements in depression (5/7), stress (5/7), general wellbeing (5/7), anxiety (4/7), and voices (3/5). One showed a deterioration in anxiety (1/7) and dissociation (1/7). At the group level of analysis (n=7), there were significant improvements in group mean scores of depression, stress, wellbeing, voices and delusions, and at 6-8 week follow-up, the wellbeing, voices and delusions improvements remained significant. Further investigations are required of the theoretical relationships surfacing in this thesis, as well as the evaluation of CFTp. Specifically, the future modelling and testing of three-way interacting mechanisms (dissociation x social rank x attachment) in pathways to PLEs is recommended. For CFTp to be considered as a clinical treatment, it requires further testing in a pilot Randomised Controlled Trial, with different therapists, and with researchers who are unaware of the group allocation. 3 Acknowledgements This thesis was supported by an MRC Clinical Research Training Fellowship, which paid me a part-time salary for five years (from June 2014) to study for a PhD. Without this financial input, it would not have been possible to conduct a project of this size, and to write a thesis, whilst also supporting my young family of five. Much gratitude therefore to the MRC for funding this work and to the Department of Psychology at IoPPN, King’s College London for helping me put together a successful grant application. I would like to acknowledge the 609 participants who shared their personal experiences with me across the various studies, and particularly the seven of them who talked with me at great length and detail for the therapy study (at least 30 hours each) whilst courageously engaging with the most distressing parts of their experience. I feel deeply honoured to have been given access to this vast pool of wisdom and insight, and I sincerely hope that I have done some justice to this in my reporting. I am very grateful to the support and guidance from my PhD supervisors, Dr Emmanuelle Peters, Prof Dame Til Wykes, and Prof Andrew Gumley. I have huge admiration for Emmanuelle’s remarkable attention to detail. Nothing sneaks past Emmanuelle. Ever. Although this can be daunting at times, it is also incredibly validating to experience someone with such knowledge and expertise so generously giving their time and concentration to your work. Til’s wonderful ability to get to the point and elicit action is second to none, and Andrew’s caring presence and intellectual guidance over the final two- year stretch in Glasgow was hugely valuable. Detail, action, and care: that’s what I call a dream team. My acknowledgements and gratitude also to the clinical supervisors on my PhD, Prof Paul Gilbert and Dr Chris Irons. I feel very fortunate to have learnt Compassion Focused Therapy from the founder and world experts, and the generous input from both on this project has taken many forms beyond their clinical supervisory roles. My wonderful comrade, Dr Eleanor Longden, who has heavily shaped my learning about how to help people with psychosis; our collaboration on the PhD has produced writings, trainings, resources, and friendship. Kate Anderson, the talented artist who brought ‘Compassion for Voices’ to life through animation so that a central message of my PhD could be shared with the world. My ‘CAVEtalk’ peer supervision group, in particular, Elisabeth Svanholmer and Rufus May. Karlijn Hermans, my excellent MSc Erasmus student, who was a great ally in data collection and grappling with statistics. My fellow PhD students with whom I’ve shared offices, especially Pamela Jacobsen, who knows how to create an
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