Summary SMI

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4.3C Severe Mental Illness in Urban Context Course

Summary
4.3C Severe Mental Illness in Urban Context (Erasmus Universiteit Rotterdam)
StudeerSnel wordt niet gesponsord of ondersteund door een hogeschool of universiteit

Gedownload door Beatriz Berghöfer ([email protected])
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THEME 1
LITERATURE
SLADE – CHAPTER 1
Personal recovery = a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills, and/or roles.
- It is a way of living a satisfying, hopeful and contributing life even within the limitations caused by illness
- It involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects
of mental illness
THE PROBLEM
People using mental health services lie on a spectrum:

1. People who benefit from mental health services as currently structured, typically contains people who are progressing well in life
and are then struck down by a mental illness.
- The application of effective treatments helps the person to get back to normal – to come to view the mental illness
experience as a bump in the road of their life, which they get over and move on from
2. People for whom mental health services promise but do not fully deliver.
- The impact of mental illness does lessen over time, but it is not clear how much this is because of the treatment and how
much because of other influences
3. People for whom the mental health system, with its current preoccupations, imperatives and values, is harmful.
- The impact of mental illness increases over time, to the point where their whole identity is enmeshed with the mental
patient role
- Mental health services are currently configured as toxic
AIMS OF THE BOOK
The books is written primarily for mental health professionals and has three aims in relation to personal recovery:
1. To convince that a focus on personal recovery is a desirable direction of travel for mental health services.
Five broad reasons are proposed:
• The epistemological rationale – the experience of mental illness is most helpfully understood from a constructivist perspective,
which necessarily involves giving primacy to the values and preferences of the individual.
• The ethical rationale – that an emphasis on professionally judged best interests has inadvertently done harm, and a better approach
would involve support oriented around the individual’s goals rather than around clinical imperatives.
• The effectiveness rationale – that the benefits of the most common treatment (medication) have been systematically exaggerated,
and a broader approach is needed.
• The empowerment rationale – that a focus on clinical recovery has consistently involved the interests of the individual person with
a mental illness being subordinated to the interests of other dominant groups in society – ‘their’ life has not been safe in our hands.
• The policy rationale – in many countries, public sector mental health professionals have been told to develop a focus on personal
recovery.
2. To crystallize exactly what personal recovery means.

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This is addressed in two ways:

• A Personal Recovery Framework is proposed.
• There are different types of knowledge: evidence which comes from group-level scientific designs is currently valued in the scientific
literature more than evidence that comes from individuals. The pendulum has swung too far, and what is needed is a blending of
group-level and individual-level evidence.
3. To catalyze – to provide a response to the mental health professional who is convinced about the values, has crystallized beliefs
and knowledge about personal recovery, and wants to know where in practice to start. Case studies of best practice from around the
world care included.
NEW GOALS, VALUES, KNOWLEDGE AND WORKING PRACTICES
• The primary goal of mental health services needs to change, from its current focus on treating illness in order to produce clinical
recovery, to a new focus on supporting personal recovery by promoting well-being.
• Supporting personal recovery requires a change in values. The new values involve services being driven by the priorities and
aspirations of the individual, rather than giving primacy to clinical preoccupations and imperatives. This will involve mental health
professionals listening to and acting on what the individuals themselves say.
• New knowledge will be needed, because the treatment of illness and the promotion of well-being require different, though
overlapping, actions. The science of illness provides only limited levers of change. Development of well-being is a long-term
process, and involves different tasks.
• What does this mean in practice? A theory-based Personal Recovery Framework, which is based on four key processes involved
in the journey to recovery:
1. Hope
2. Identity
3. Meaning
4. Personal responsibility
SLADE – CHAPTER 2
WHAT IS MENTAL ILLNESS?
• The starting point for understanding mental illness is as a subjective experience.

• Mental illness differs from physical illness: once a physical marker is found, it moves to another branch of medicine and ceases to
be viewed as a mental illness.
• Overall, the pragmatic meaning of mental illness is a disorder with no established physical cause: a functional illness.
• There are three broad ways of understanding mental illness:
1. Clinical models: bio-medical, bio-psycho-social, cognitive.
2. Disability models
3. Diversity models
1. CLINICAL MODELS
• Ways of seeing the world which have been developed by the various mental health professions and which inform day-to-day clinical
practice.

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• Clinical models of mental disorder use evidence from clinical science, with a focus on accurate assessment of the individual
followed by application of the evidence base to identify the most effective treatment.
CLINICAL MODEL 1: BIO-MEDICAL
The biomedical model of illness involves two key assumptions:

1. An illness has a single underlying biological cause (a disease).
2. Removal of the disease will result in a return to health.
• Neither assumption is universally true in relation to mental illness.

• This model is a model of psychopathology, in which listening is used to elicit phenomena of psychopathology.
• The approach of eliciting features of psychopathology through mental state examination is a core feature of the biomedical model
of mental illness.
• The problem with this (expressed by Lucy Johnstone) is that personal meaning is the first and biggest casualty (slachtoffer) of the
biomedical model.
CLINICAL MODEL 2: BIO-PSYCHO-SOCIAL
The bio-psycho-social model proposes that mental illness does not exist in a biological vacuum, and recognizes that
interpersonal, contextual and societal factors impact on the interpretation, onset, course and outcome of mental illness.
• Based on a stress-vulnerability diathesis – that an internal vulnerability interacts with an aversive environment to produce
psychotic experiences.
• In reality, the bio-psycho-social model is far more closely aligned with a biologically focused bio-medical model than with either
psychological or social models.
• The key indicator of a bio-medical model of illness – diagnosis – remains central to the bio-psycho-social model, rather than one of
three equally valued components.
To understand why there is a problem, it is helpful to illuminate the core assumptions and evolved working practices of the bio-
medical and the bio-psycho-social clinical models:
Domain Dominant concept/approach

Responsibility and relationships
Ethical imperatives on clinicians Acting in best interests, responsibility for the patient
Clinician’s primary responsibility To diagnose and treat the mental illness
Patient’s primary responsibility To take treatment as prescribed
Clinician’s relationship with patient Expert and authoritative
Assessment
Basic understanding of mental illness Psychopathology resulting from disturbed homeostasis
Assessment focus Intrapsychic deficits and problems
Meaning attributed by the patient Peripheral
Assessment goal To identify the mental illness and hence make a diagnosis
Action
Driver for clinical and patient action Avoidance motivation – the avoidance of symptoms or suffering
Focus of action Clinicians treating the patient

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Proximal aim of treatment Symptom reduction, functional improvement

Distal aim of treatment Cure the illness
Evaluation of treatment success By the clinician, through objective outcome assessment
Meaning of recovery Restoration of disturbed homeostasis – getting back to normal
These assumptions do not fit reality in four ways:
MISMATCH 1: MENTAL ILLNESS IS NOT (ONLY) CAUSED BY DISTURBED HOMEOSTASIS
• The Jasperian distinction between understanding and explaining is crucial:

- Understanding is an interpretation or a partial way of a phenomenon, but since there are always may possible
interpretations, no single understanding is intrinsically superior – they cannot be ranked a priori (therefore, the
usefulness of a particular understanding should be judged in relation to whether it is helpful, not whether it is true)
- Explanation reveals something of the essence of a phenomenon and can be ranked – the best explanations most
closely fit current observable data and are a better predictor of the future
• The center of gravity of the bio-medical and the bio-psycho-social model is diagnosis, but there is a key difference between
diagnoses of physical and mental illness:
- A diagnosis of physical illness provides an explanation: it tells us something of what is going on (etiology) and how
things will unfold (prognosis), irrespective of what the person believes or the social context of the patient
- A diagnosis of mental illness is an understanding: its utility depends crucially on the beliefs and context of the patient
and whether they find it a useful way of making sense of the experience (it is descriptive, not explanatory)
• Pawson and Tilley argue for a move from a successionist to a generative model of causation, in which “causal outcomes follow from
mechanisms acting in contexts”. Prediction can then be made through an understanding of the causal mechanisms linking input
with outcome and of the contextual factors influencing these processes.
- Successionist theory = causation is unobservable, and observational data are the only mechanism for inferring
causality, which leads to the methods of experimental manipulation and pre-post-comparison of experimental and
control groups.
- Generative theory = there is an observable connection between causally connected events, and internal features of
the thing being changed are central to understanding causality.
• This distinction allows an unpicking of two meaning of the term ‘mental illness is caused by disturbed homeostasis’:
1. Mental illness is observable in the biological substrate.
- This is true but uninteresting, because all human feelings and behaviors can be observed at the level of biology but they
can also clearly be understood as psychological or social phenomena
- It may of course be helpful to understand the biological correlates of mental illness, since these may provide points of
remedial intervention, but they do not explain mental illness
2. Mental illness occurs as a result of disturbed homeostasis.
- “All would be well if it were not for the imbalance in these internal processes, and mental illness exists and can be
explained in isolation from psychological and social context”
- Identification of invariant final common pathways which are biological or effective treatments targeting restoration of
homeostasis only impacts on how useful the understand is – it does not provide an explanation
- Mental illness is not essentially biological
• Increasing understanding at any modality (e.g., biological, psychological, etc.) is a welcome scientific advance, but does not – and
cannot – provide the explanation of experience.
MISMATCH 2: DIAGNOSIS DOES NOT ‘CUT NATURE AT ITS JOINTS’

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• A consequence of viewing diagnosis as a partial understanding rather than as revelatory explanation is that there cannot be stable,
invariant (over time and culture) psychopathological diagnostic categories.
• The two powerful forces which have led to this avalanche of diagnostic categories are:
1. A consequence of Enlightenment values – human pain and suffering would be overcome by the advance of rationality
and science. Psychiatry has attempted to replace spirituality, moral, political and folk understanding of madness with the
framework of psychopathology. The culmination of this was the ‘decade of the brain’ when it was firmly asserted that the
causes of madness are to be found in neurotransmitter abnormalities.
2. A confluence of commercial and professional interests – the greater the spread of diagnostic categories, the more
money is to be made in treating these conditions, and the more influence can be obtained by mental health professions.
• This increase in diagnostic categories is not science – it is colonization of the human condition. It is also not a neutral activity – it
directly impacts on social understandings of human experience. If clinical practice is to match reality, then it needs to be recognized
that diagnosis is one of many ways of making sense of experience.
MISMATCH 3: ASSESSMENT PROCESSES CREATE STIGMA
• Clinical assessment should cover four dimensions:

1. Deficiencies and undermining characteristics of the person
2. Strengths and assets of the person
3. Lacks and destructive factors in the environment
4. Resource and opportunities in the environment
• However, to make a diagnosis only dimension 1 needs to be considered. Since assessment in bio-medical and bio-psycho-social
models is oriented towards making a diagnosis, clinical interactions tend to focus on dimension 1.
• This focus leads to three problems:
1. Deindividuation – the process of labelling leads to perceptions of diminished within-group differences and
exaggerated between-group differences. People with the same mental illness are fundamentally different from each
other, and a key problem with diagnosis is that it ignores these differences.
2. Neglect of environment – the focus on individual over environment is discordant with the experiences of people with
mental illness, with the result that “many of them find bio-medical interpretations limited – at best unhelpful, and at
worst harmful”.
3. Negative bias – if something about the person stands out sufficiently (has sufficient salience, such as a diagnostic label
presented as an explanatory fact) and is regarded as having a negative value (has stigmatizing associations), and if the
context is vague or sparse (nothing else is known about the person), then this will adversely influence views about the
person. Use of diagnosis as an explanation accompanied by neglect of the environment leads directly to a negative
perception of the person.
MISMATCH 4: TREATMENT DOES NOT CURE
• Naïve psychiatric practice is based on a belief that treatment makes people recover, and so the job of the medical professionals is to
deliver treatment. Treatment involving the clinician doing something to the patient is the norm (instead of doing something with
the patient or the person doing something for themselves).
• The problem with this approach is that the promise of treatment leading to cure is not delivered. Creating an expectation that
the expert clinician will treat and cure the patient is actively unhelpful.
• A focus on treatment as something done to the patient has two specifically damaging effects:
1. It locates the primary responsibility for change in the wrong place – with the clinician rather than with the patient.

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2. It constrains (beperkt) possible solutions – interventions to promote resilience are unlikely to be considered.
PRAGMATISM VS CONSISTENCY
• Four pragmatic arguments might justify the unreserved and invariant use of a clinical model to make sense of a person’s experience:
1. The model is the only way of understanding the experience
2. The benefits always outweigh the costs
3. The model predicts prognosis
4. The resulting actions cure the patient
• It can be argued that all four justifications are present for many physical illnesses, however, none of the conditions are satisfied for
mental illness:
1. The existence of multiple credible models of understanding mental illness is apparent.
2. This is actually a statement of values, since comparing costs and benefits involves putting value on each. Placing more
value on the experiences, aspirations and preferences of the patients would significantly change the cost-benefit analysis
away from the imposition of clinical models
3. Accurate prognosis doesn’t follow from the use of bio-medical or bio-psycho-social models.
4. Consistent cure doesn’t follow from the use of bio-medical or bio-psycho-social models.
CLINICAL MODEL 3: COGNITIVE
• The central insight of the cognitive model of mental disorder is that cognitions (beliefs) matter. The way we see the world, the
interpretations we put on events, the expectations we have about how things will turn out, and our self-image all influence what
experiences we have.
• The key distinction from the bio-medical model is the emphasis on interpretation mediating experiences.
• Four traditional assumptions:
1. Clinical psychology is concerned with psychopathology – deviant, abnormal and maladaptive behavior and emotional
conditions.
2. Psychopathology, clinical problems and clinical populations differ in kind, not just degree, from normal problems in
non-clinical populations.
3. Psychological disorders are analogous to biological or medical diseases and reside somewhere inside the individual.
4. The clinician’s task is to identify (diagnose) the disorder (disease) inside the person (patient) and to prescribe an
intervention (treatment) that will eliminate (cure) the internal disorder (disease).
• So, the language of the clinical psychology remains the language of the medicine and pathology – what may be called the language
of the illness ideology.
• CBT is individualized in the sense that it is based on a person-specific formulation rather than a diagnosis, and has the potential to
restore meaning and personal responsibility, but CBT still has an emphasis on interpretation of phenomenological experience rather
than a focus on poverty, abuse, homelessness, or other socially and interpersonally toxic life events. CBT remains embedded in a
psychopathology framework and is congruent with many of the same assumptions about underpinning psychopathology as bio-
medical and bio-psycho-social models.
2. DISABILITY MODELS
The social disability model for mental illness holds that a person is disabled if he/she is, for example, blind, and experiences
barriers and exclusion as a result. The term is not limited to those who ‘use’ blindness services nor to people who are ‘surviving’. It

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covers everyone affected by discrimination on the grounds of the supposed imperfection of disability. It allows for transforming
negative associations into positive ones, through disability pride.
• Advantages of this approach:

1. It does not presume a particular construction of understanding – medical, psychological, familial, societal, cultural and spiritual
constructions can all be accommodated.
2. The alignment is increased between mental illness and other, more established, disability groups. A social disability model
encourages the use of treatments and support which keep the individual in their life.
3. This alignment de-emphasizes the illness, and the issue moves from ‘What’s the matter with you?’ to ‘What do you need to do your
job or live your life?’. The focus on adaptation includes both the need for the individual to adapt to the new and changed reality of
their life, and (because of the adverse social consequences) the contribution of a socially inclusive and accessible environment. This
leads to a more holistic view of the person-in-context.
• Three levels of impact:

1. The illness: the direct impact of the symptoms – people in contact with mental health services often present with high levels of
distress caused by their experiences.
2. The treatment: a social disability model highlights that treatment is not only about making an ‘ill’ person ‘well’, but brings into
view a wider set of questions about the impact of treatment:
- Autonomy and responsibility – enhancing autonomy by generating an internal locus of control
- The centrality of social roles – encouraging a sick role can be toxic, while promoting work and relationships can be a
cause of mental well-being
- The harmful aspects of treatment – treatment which marks someone out as different reduces the opportunities for the
person to be accepted into society
- Hopefulness and hopelessness – interventions which create dependency or passivity or promote hopelessness are
damaging
3. The social consequences: stigma has three elements
- Ignorance = problems of knowledge
- Prejudice = problems of negative attitudes
- Discrimination = problems of behavior
• Advantages of a social disability model in the domain of work and employment:

- Offers a more helpful conceptual basis for understanding and promoting employment opportunities for people who use
mental health services and offers more hope of recovery of social roles
- Better captures the experience of discrimination and exclusion central to the lives of many mental health service users
and addresses the barriers to employment
- It is consistent with current government policy
- It is consistent with the views of users and people with disabilities
- It assists in achieving dialogue with employers
3. DIVERSITY MODELS
Diversity models align with other liberation movements, and focus on emancipatory changes needed in society rather than
either treatment of, or adaptation by, the individual.

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• Diversity models challenge three embedded assumptions:

1. Mental illness experiences are psychopathological
- Anthropological research shows that mental health practice constructs mental illness as an external entity, but diversity
models challenge this construction and instead focus on the need to integrate all aspects of human experience
(including those labelled by others as ‘mental illness’) into a proud and coherent self-identity
- Part of this involves challenging the illness-based, and consequently negative, values by re-appropriating language
2. Mental illness is dichotomous – people are either normal or mentally ill
- Disease generally exists as a continuum of severity rather than as all-or-non phenomena
- The distinction between mental illness and other forms of deviation from normality may be subjective rather than
objective
3. Mental illness is wholly negative
- High achievement and mental illness can co-exist!
- So, a severe mental illness label should not, from an empirical perspective, lead to impoverished expectations
- There are first-person accounts of life being deeper, stronger or richer after mental illness has struck
• Implications:
- Rationalism is not given automatic primacy as a superior state
- The balance of power changes
- Some need for separatism
- Much greater attention paid to the empowerment of the individual, and awareness of sociocultural pressures and
assumptions
ADJUDICATING BETWEEN MODELS
Clinical model Disability model Diversity model

Source of problem Illness in the person The combination of mental Society
illness and societal response
Treatment Necessary and appropriate Necessary but insufficient Only if wanted, never if not
wanted
Expertise In the professional Shared In the consumer
Central role of the Providing evidence-based Advocacy (belangenbehartiging) Supporting consumer activism
mental health treatments
professional
Role of the mental Taking treatment Developing inter-dependence – Accepting and valuing oneself,
health service taking appropriate support and losing self-stigmatizing beliefs
user developing self-management
skills
Strengths Provides a clear explanatory De-emphasizes illness, Doesn’t pathologize, places
model, and leads to well- encourages social inclusion, power in the hands of the
developed treatments consistent with existing disability individual consumer
discrimination legislation
Weaknesses Doesn’t fit for everyone, Retains paternalistic approach How to gate-keep support
promises care but doesn’t resources if everyone is
deliver ‘normal’?
• Each model has its merits and, in the absence of comparative data, it is not possible to adjudicate between them.
• Each model is simply a hypothesis – the current reasonable explanation of the facts.

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• Therefore, an authentic (rather than simply expressed) tentativeness is needed in applying the model to an individual.
THE LANCET – BELGIAN SUPERIOR HEALTH COUNCIL ADVISES AGAINST THE USE OF THE DSM
CATEGORIES
• Epistemologically, the expert group concluded that mental disorder categories should not be treated as natural kind categories,
but as constructs that have a causal impact on those who are classified.
• Sociologically, the group observed that diagnostic classifications tend to legitimize organizational structures and protect
psychiatry from pressures to change. A bio-medical approach does not, as hoped, reduce stigma and discrimination.
• Clinically, the group concluded that common diagnostic categories lack validity, reliability, and predictive power. These do not
tally with new conceptions of health, defined by the ability to adapt despite bio-psycho-social obstacles.
• The council observed that multilayered clinical case formulation provides a useful alternative.
- Symptoms, complaints, and suffering can best be contextualized in terms of biographical information, existential
challenges, contextual-interactional functioning, mental processes, and biological considerations
- Classification can still occur but on the basis of a small number of general syndromes, which stimulates personal
diagnostic formulation
- These should be discussed in terms of a continuum from crisis to recovery to assess the need for care and support
• The report ends with recommendations that encourage contextualized patient-centered psychiatry.
• Five key recommendations:

1. Default non-problematizing and non-medicalizing approaches to mental complaints or crises because they might express
existential and social problems.
2. Careful listening to subjective experiences.
3. Providing help and support for mental complaints or crises without a formal diagnosis as a precondition.
4. Taking the perspective of people with mental complaints or crises and the way in which they give meaning as central to
diagnosis and treatment.
5. When formulating a case, paying close attention to the person-specific way in which, among others, mental, existential (giving
and losing meaning), biological, social, and cultural factors take shape.
WESTEN, NOVOTNY & THOMPSON-BRENNER – THE EMPIRICAL STATUS OF EMPIRICALLY SUPPORTED

PSYCHOATHERAPIES: ASSUMPTIONS, FINDINGS, AND REPORTING IN CONTROLLED CLINICAL TRIALS
• Critical review of the assumptions and findings of studies used to establish psychotherapies as empirically supported.
• The attempt to identify empirically support therapies (ESTs) imposes particular assumptions on the use of RCT methodology that
appear to be valid for some disorders and treatments (exposure-based treatments of specific anxiety symptoms) but substantially
violated for others.
• Meta-analytic studies support a more nuanced view of treatment efficacy than implied by a dichotomous judgment of supported
versus unsupported.
• The authors recommend changes in:
- Reporting practices to maximize the clinical utility of RCTs
- Describe alternative methodologies that may be useful when the assumptions underlying EST methodology are violated

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- Suggest a shift from validating treatment packages to testing intervention strategies and theories of change
that clinicians can integrate into empirically informed therapies.
RETELLING THE STORY: THE ASSUMPTIONS UNDERLYING ESTS
• ESTs share a number of characteristics:

- Typically designed for a single Axis I disorder
- Patients are screened to maximize homogeneity of diagnosis and minimize co-occurring conditions that could increase
variability of treatment response
- Treatments are manualized
- Treatments are of brief and fixed duration to minimize within-group variability
- Outcome assessment focuses primarily (though not necessarily exclusively) on the symptom that is the focus of the study
• The use of RCT methodologies to validate ESTs require a set of additional assumptions that are themselves neither well validated
nor broadly applicable to most disorders and treatments.
• The authors are not arguing that these assumptions are never valid, but they are not generally valid – that is, they apply to some
instances but not others.
1. PSYCHOLOGICAL PROCESSES ARE HIGHLY MALLEABLE
The assumption of malleability is implicit in the treatment lengths used in virtually all ESTs, which typically range from about 6
to 16 sessions, but this focus on brief treatments emerged less from any systematic data on the length of treatment required to treat
most disorders than from pragmatic considerations, such as the fact that if psychotherapy researchers were to compare their
psychotherapies with medications, they needed to avoid the confound of time elapsed and hence tended to design treatments of
roughly the length of a medication crossover design.
• The longer the therapy, the more variability within experimental conditions; the more variability, the less one can draw causal
conclusions.
• The malleability assumption is also inconsistent with data from naturalistic studies of psychotherapy, which consistently find a dose-
response relationship, such that longer treatments, particularly those of 1 to 2 years and beyond, are more effective than
briefer treatments.
• Of particular relevance is the finding from naturalistic samples that substantial symptom relief often occurs within 5 to 16 sessions,
particularly for patients without substantial personality pathology; however, enduring ‘rehabilitation’ requires substantially
longer treatment, depending on the patient’s degree and type of characterological impairment.
• Many psychopathological vulnerabilities are in fact resistant to change, and many are rooted in personality and temperament.
The modal patient with brief treatments for most disorders relapses or seeks additional treatment within 12 to 24 months.
2. MOST PATIENTS HAVE ONE PRIMARY PROBLEM OR CAN BE TREATED AS IF THEY DO
The assumption that patients can be treated as if they have one primary, discrete problem, syndrome, or disorder – and the
correlative assumption that if they have more than one disorder, the syndromes can be treated sequentially using different manuals
– again reflects an admixture of methodological constraints and theoretical meta-assumptions.
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• Including patients with substantial comorbidities would vastly increase the sample size necessary to detect treatment differences
if comorbidity bears any systematic relation to outcome. The most prudent path is arguably to begin with relatively ‘pure’ cases,
to avoid confounds presented by co-occurring disorders.
• The requirement that research proposals be tied to categories defined by the DSM to be considered for funding has virtually
guaranteed a focus on single disorders.
• Three costs of linking treatment research to DSM-defined categories:
1. DSM diagnoses are themselves created by committee consensus on the basis of the available evidence rather than by strictly
empirical methods, and in many cases, they are under serious empirical challenge.
2. The implicit assumption that patients typically present with symptoms of a specific Axis I diagnosis and can identify at the start of
treatment precisely which one it is, is not generally valid. Between one third and one half of patients who seek mental health
treatment cannot be diagnosed using the DSM because their problems do not fit or cross thresholds for any existing category.
3. The sheer number of disorders in the DSM renders the notion of clinicians learning disorder-specific manuals for more than a
handful of disorders unrealistic.
• Aside from the problem of linking treatment manuals for DSM-defined disorders is the question of whether, in fact, patients in
clinical practice typically present with one primary disorder. The literature on comorbidity in both clinical and community samples
suggests that single-disorder presentations are the exception rather than the rule. Studies consistently find that most Axis I
conditions are comorbid with other Axis I or Axis II diagnoses in the range of 50% to 90%. One cannot routinely assume that
psychopathology is additive or can be treated as such.
• The function of assessing for co-occurring conditions differs in research and practice in a way that can affect the generalizability
of ESTs. Researchers typically begin by soliciting patients with a particular disorder and exclude them if they have co-occurring
conditions (either implicitly or explicitly). Clinicians typically do not assume that one symptom or syndrome is primary. Rather
than starting with one symptom or syndrome in mind, clinicians are likely to inquire broadly about the patient’s symptoms, history,
and so forth. Not to decide whether to refer them elsewhere but to understand them better. Moreover, in clinical practice, symptoms
initially identified as primary may not remain the focus of treatment over time, even if the clinician is appropriately responding to
the patient’s concerns.
3. PSYCHOLOGICAL SYMPTOMS CAN BE UNDERSTOOD AND TREATED IN ISOLATION FROM

PERSONALITY DISPOSITIONS
The assumption that psychological symptoms can be understood and treated in isolation from the personality of the person who
bears them is essential to the methodology of ESTs, in large measure because of the brief, focal nature of treatment required to
maximize experimental control and in part because of the focus on syndromes rather than processes or diatheses.
• The assumption that Axis I conditions can be treated as if they were independent of enduring personality dispositions has two
complications, one empirical and one methodological:
- Empirically, most Axis I syndromes are not independent of personality, and personality often moderates treatment
response
- Pragmatically, including patients who share a diagnosis such as depression but vary considerably in personality would
require using sample sizes that are substantially larger than either customary or tenable for establishing ESTs
• Accumulating evidence suggests that the first part of this assumption, that Axis I symptoms or syndromes can be understood apart
from personality processes, is inaccurate for most disorders.
- Studies suggest that Axis I anxiety and mood disorders are systematically related to variables long considered personality
variables, notably high negative and low positive affect
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- Different kinds of personality diatheses, such as vulnerability to loss versus vulnerability to failure, predispose different
individuals to become depressed under different circumstances
- The prevalence of comorbid Axis I conditions in patients treated for disorders such as depression, GAD, PTSD, and bulimia
may actually provide an index of the prevalence of underlying personality diatheses
- The same Axis I symptom or syndrome may have different functions or implications in the presence of certain kinds of
personality disturbance
- Patients treated for Axis I conditions often fare less well if they also have certain personality disorders, particularly BPD
- The concept of comorbidity may be misleading because it implies that personality variables are an add-on to a symptom
picture that is essentially distinct from them
- From a treatment perspective, the high correlations between trait anxiety and depression, and the substantial comorbidity
between major depression and virtually every anxiety disorder, suggests that researchers might do well to develop
treatments for negative affectivity and emotional dysregulation rather than focusing exclusively on DSM-defined
categories
• The prevalence of personality diatheses for psychopathology presents a methodological paradox. If researchers include patients
with substantial personality pathology in clinical trials, they run the risk of ambiguous conclusions. If they exclude such patients,
one cannot assume generalizability to a target population that is rarely symptomatically pure.
4. CONTROLLED CLINICAL TRIALS PROVIDE THE GOLD STANDARD FOR ASSESSING THERAPEUTIC
EFFICACY
Perhaps the most central assumption underlying the enterprise of establishing ESTs is that RCT methodology provides the gold
standard for assessing the efficacy of psychotherapeutic interventions.
THE FUNCTIONS OF MANUALIZATION
• A key component is that the elements of efficacious treatment can be spelled out in manualized form and that the interventions
specified in the manual are the ones that are causally related to outcome
• EST methodology imposes constraints on the ways manualization can be implemented that limit its flexibility and utility in
generating scientifically and clinically useful data. The best manual is one that can standardize the ‘dose’, the timing of the dose,
and the specific ingredients delivered in each dose. This places a premium on development of treatment packages that minimize
clinical judgment. Historically, manuals did not arise as prescriptions for clinical practice, but manualization was simply a method
for operationalizing what investigators were trying to study. Put another way, a reversal of means and ends is taking place
whereby manuals are not just convenient ways of operationalizing treatments in the laboratory but are the defining features of the
treatments themselves.
• Along with this shift in means and ends has come a shift from the study of treatment principles to the validation of treatment
packages and a corresponding shift in the function of manuals from a descriptive one (allowing researchers to describe their
experimental manipulations precisely) to a prescriptive one (standardization of clinical activity in everyday practice, so that
clinicians carry out interventions in the precise ways that they have been tested).
• Where patients have a substantial degree of control over the content or structure of treatment hours, therapists by definition have
less control. Where therapists have less control, standardization is diminished and within-group variance attributable to sources
other than standardized technique is correspondingly increased.
• The paradox of manualization is that the patient’s active involvement in treatment is likely to be essential to good outcome but
destructive of experimental control.
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• Example of the manual of IPT for bulimia, which leaves out talking about the eating disorder because that was already a part of the
CBT treatment with which it was compared. They hypothesized that CBT would be a better treatment, but by their surprise, IPT was
better. So, they started using the manual for IPT in practice, with the essential feature of talking about the eating and craving left
out. Not because not talking about eating and craving was actually proven to be beneficial for the patient, but simply because it
wasn’t in the manual that was tested.
DISMANTLING THE SCIENTIFIC TESTING OF TREATMENT PACKAGES
• The elements of efficacious treatment are dissociable and hence subject to dismantling.
• The process of selecting the particular package of interventions the investigators selected is, in the philosopher of science Karl
Popper’s term, a prescientific process (i.e., prior to hypothesis testing), and one that has set the agenda for the subsequent
scientific process of testing this manual against other treatments and control conditions. Or to use the language of Paul Meehl, it is
a prime example of clinical prediction. The reality is that researchers generally solidify treatment packages (manuals) so early on
the basis of so little hard data on alternative strategies, even within the same general approach, that clinicians have to accept on
faith that the treatment as packaged is superior to the myriad variants one could devise or improvise with a given patient.
• Investigators may do better to focus RCT methodology on the testing of interventions, intervention strategies, and processes of
change rather than putatively complete treatments and to strive for guidelines that foster the practice of empirically informed rather
than empirically validated psychotherapies.
SCIENCE AND PRESCIENCE: SELECTION OF TREATMENTS TO TEST AS A SOURCE OF BIAS
• Another significant caveat is the problem of determining which treatments to test.

• Because of its requirements of brevity and experimenter control, the methodology of ESTs has precluded the testing of
treatments widely used in the community, leading to the conclusion that such treatments are empirically unsupported.
• The influence of prescientific processes can lead to scientifically invalid conclusions despite the safeguard of scientific method
imposed at the level of hypothesis testing. There can be no more powerful way to create a gulf between clinical practice and research
than to compare laboratory-derived interventions with everything but what clinicians practice in the community.
INCOMPATIBILITIES BETWEEN THE REQUISITES OF EXPERIMENTAL DESIGN AND PRACTICE
• The final problem with the assumption that experimental methods provide a gold standard for separating the clinical wheat from
the chaff is the extent to which the requisites of experimental research aimed at identifying ESTs can diverge from the
requisites of good treatment, leading to a state of affairs in which the methodological tails wags the clinical dog.
• A researcher testing a novel intervention in an RCT needs to control for common factors to test its incremental efficacy, but this
does not mean clinicians should do so.
• The uncommonly differentiated factors paradox = to maximize detection of clinically and statistically significant between-
groups effects for ESTs, researchers need to design treatments that are maximally differentiable. Doing so, however, renders them
vulnerable to developing treatments that lack precisely the factors that produce much of the effect of brief psychotherapies for many
disorders.
RETELLING THE STORY: A REEXAMINATION OF THE DATA SUPPORTING ESTS
MULTIDIMENSIONAL META-ANALYSIS: AGGREGATING A RANGE OF INDICATORS OF OUTCOME
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• Effect size estimates are essential in evaluating the efficacy of a psychotherapy; however, they have certain limits:
- Pre-post effect size estimates are difficult to interpret because passage of time, regression to the mean, spontaneous
remission in disorders with fluctuating course, tendency to present for treatment when symptoms are particularly
severe, and other variables not specific to a given treatment can lead to symptomatic change over time
- Treatment-control effect size estimates provide a better estimate of the extent to which a treatment is useful for the
average patient, but they do not provide information on clinically meaningful variation in treatment response (a
treatment that has an enormous effect in 20% of patients can appear superior to another treatment that has a smaller but
clinically meaningful impact in 90% of patients)
• Percentage improved or recovered is an essential meta-analytic complement to effect size estimates and has a number of
variations that need to be distinguished:
- Numerator (the number of patients who improved): how does one define clinically significant improvement or recovery?
- Denominator (the number improved in relation to whom, i.e., success rates divided by what number?): percentage
improved can be calculated relative to the number of patients who complete treatment or the number who entered
treatment
Ø If dropouts are as high as even 20% - which they usually are – these metrics can yield very different estimates of
improvement or recovery
- Average level of symptomatology after treatment
- When to measure outcome: initial response and sustained efficacy
- Outcome at long-term follow-up intervals: important distinction between percentage improved or recovered at follow-up,
and the percentage that remained improved or recovered at follow-up
- Generalizability: percentage of potential participants excluded at each step of screening
EFFICACY OF ESTS FOR COMMON PSYCHOLOGICAL DISORDERS: A META-ANALYTIC REASSESSMENT
Empirical support is a matter of degree, which varies considerably across disorders.
EFFICACY OF TREATMENTS FOR DEPRESSION, PANIC, AND GAD
• Although the average patient improved substantially in active treatment conditions, the average patient also remains
symptomatic. For all three disorders, long-term follow-up data were almost nonexistent, and where they did exist, they tended to
support only treatments for panic.
- Depression: only 1/3e had improved and remained improved over 2 years
- Panic: roughly 1/2e of the patients who entered or completed treatment improved and remained improved
- GAD: no data on efficacy at 2 years or beyond
• Generalizability: exclusion rates ranged from 65% for GAD to 68% for depression. Thus, the average study excluded 2/3e of patients
who presented for treatment. The fact that such a high percentage of patients had to be excluded across all three disorders suggests
that comorbidities of the types excluded may be the rule rather than the exception.
EFFICACY OF TREATMENTS FOR BULIMIA NERVOSA AND OCD
• Bulimia nervosa:
- Effect sizes were substantial (0.88 for binge eating and 1.01 for purging)
- Most patients continued to be symptomatic
- 40% recovered (of those who completed treatment), 33% recovered (of those who entered treatment)
- Substantial improvement from baseline (though still symptomatic)
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- Only 1/3e showed sustained recovery at 1 year

- Exclusion rate: 40%
- Psychopharmacology appears to be useful in many cases as an adjunctive treatment, but outcomes obtained using
medication alone do not compare with the results of psychotherapies such as CBT
- Medication is useful, but only in certain ways for certain patients
• OCD:
- Effect sizes very high (1.50 to 1.89 depending on the outcome measure)
- 2/3e who completed treatment improved (defined variously as 30% to 50% reduction in symptoms), and 1/3 recovered
- The average patient experienced substantial improvement but also remained symptomatic
- Exclusion rate: 62%
- Psychopharmacological treatments are much more encouraging: almost 2/3e who completed and 1/2e of those who
entered a medication trial improved
- Data on medication for OCD are much stronger in terms of effect size, but medication rarely leads to cure
COMPARING ESTS AND NATURALISTIC STUDIES OF PSYCHOTHERAPY
Naturalistic studies provide a window to phenomena not readily observed in the laboratory and can be particularly useful both for
hypothesis generation and for providing a context within which to interpret data from RCTs, particularly data bearing on external
validity.
• Two findings are of particular relevance:

1. Median treatment lengths ranged from 52 sessions for panic to 75 sessions for depression. The briefest treatments were cognitive-
behavioral, and even these treatments were almost twice as long on the average as manualized CBTs for the same disorder.
2. Comorbidity was the norm rather than the exception. Across disorders and theoretical orientations, average treatment length
doubled when patients had any form of Axis I or Axis II comorbidity, and the presence of clinically significant personality problems
also predicted treatment length.
• Greater use of CBT interventions was associated with more rapid remissions of eating symptoms, whereas greater use of
psychodynamic interventions was associated with larger changes in global outcome.
• Clinicians of all theoretical backgrounds reported using more psychodynamic interventions when treating patients with
comorbid pathology, which is perhaps not surprising given that these interventions are more oriented toward personality.
Psychodynamic clinicians reported using more CBT interventions (such as structuring the therapy hours) with emotionally
constricted patients. In contrast, CBT clinicians reported using more psychodynamic interventions (e.g., exploring patterns in
relationships, exploring sexuality, and exploring unconscious processes) when treating emotionally dysregulated patients (i.e.,
those with borderline features, substance use disorder, etc.).
• These data suggest that clinicians of all theoretical orientations attend to personality and comorbid symptomatology and adjust
their intervention strategies accordingly.
STUDIES TESTING THE TRANSPORTABILITY OF ESTS
A critic might object that the data presented thus far do not address the amassing literature on the transportability of ESTs to
more naturalistic settings. Within a short span of years, a number of effectiveness and benchmarking studies have found manualized
treatments to be highly transportable, with little if any decrement in effect size or response rates.
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• The authors have no doubt that many manualized treatments will ultimately show substantial transportability. However, at this
juncture, they suspect that the best way to advance knowledge of what works for whom would be to begin testing in a systematic
way the conditions under which particular treatments or interventions are likely to be useful in everyday practice, rather than to try
to make dichotomous judgments about transportability.
• Lots of research flaws in transportability studies.
REWRITING THE STORY: IMPLICATIONS FOR EVIDENCE-BASED PRACTICE
MAXIMIZING THE EFFICACY OF CLINICAL TRIALS
DESCRIBING THE HYPOTHESES AND EXPERIMENTAL CONDITIONS
• It is essential that researchers clearly label their hypotheses as primary, secondary, a priori, post hoc, one-tailed, or two-tailed.
Of particular relevance in this regard is the clear labelling of comparison and control groups.
• The frequent use of wait-list and TAU controls in RCTs for many disorders can lead to substantial problems of data interpretation.
Given that virtually any 10- to 20-session intervention will produce an initial response in most patients if carried out by a clinician
who expects it to be effective, the only scientifically valid conclusion one can draw from observed differences between experimental
and wait-list control conditions is that doing something is better than doing nothing.
• TAU conditions are often interpreted as demonstrating the superiority of experimental treatments to everyday clinical practice, but
this is only a valid conclusion if control therapists are well paid, motivated, and see the patients on a regular basis, which is seldom
the case.
• Researchers should also exercise caution in labelling control treatments not constructed to maximize their efficacy (non-bona
fide treatments, or intent-to-fail conditions) with brand names that are readily confused with genuine treatments and create sleeper
effects in the literature.
REPORTING, JUSTIFYING AND INTERPRETING DATA IN THE CONTEXT OF INCLUSION AND EXCLUSION
CRITERIA
• As a field, we would do well to stop using exclusion criteria other than those that are medically necessary or similar to those that
are medically necessary or similar to those a clinician might be expected to apply in everyday practice (e.g., brain damage) if our
goals is to guide practice.
• If researchers impose criteria other than those that are obviously necessary, they should routinely say so in the methods, results,
and discussion section.
DESCRIBING THE CLINICIANS
• Another aspect of reporting that requires greater attention regard the clinicians who conducted the treatments.
• There are no right answers to the question of how to select therapists, yet differing levels of expertise and commitment provide
one of the likely mediators of allegiance effects.
ASSESSING PSYCHOPATHOLOGY AND OUTCOME
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• The reliability and validity of assessment is obviously crucial in treatment studies and extends to the way investigators assess the
primary diagnosis for inclusion in the study, the diagnosis of comorbid conditions, and outcome.
• Outcome studies should always supplement (aanvullen) assessment of primary symptom measures in four ways:
1. They should routinely include measures of other Axis I conditions, adaptive functioning, and quality of life (because
most patients have multiple problems that affect their adaptation and life satisfaction).
2. They should include measures of relevant personality variables, particularly where data are available suggesting that
these variables may be diatheses that render the patient vulnerable to future episodes (given the strong link between
Axis I conditions and personality).
3. They should include measures designed to assess implicit networks or implicit attentional biases that may indicate
the likely durability of changes (given the growing evidence distinguishing implicit from explicit processes and linking
implicit processes to underlying vulnerabilities).
4. They should include extended follow-up in reliable and systematic ways to assess post-termination treatment seeking.
TRACKING RELEVANT NS
• Tracking precisely how many patients have come through each stage of a study is essential for assessing both efficacy and
generalizability.
• Research reports need to describe the percentage excluded at each step and the reason for exclusion.
• Definitions of dropout and completion also deserve greater attention, because they are highly variable.
• Many of the reports the authors reviewed across disorders not only failed to explain decisions about completer definitions but used
different definitions in different analyses.
REPORTING AND INTERPRETING RESULTS
• One of the primary conclusions in this article has been the importance of reporting a range of outcome statistics and
indicators of generalizability that allow readers, reviewers, and meta-analysts to draw more accurate and nuanced conclusions.
• The debate about how to measure clinical significance is an important one that will likely continue for some time. In the
meantime, the authors recommend that all published RCTs report, at minimum, each of the metrics described earlier.
• Researchers should always report means and standard deviations where appropriate, and if they switch to medians in some
analyses, they should justify the reasons for doing so.
• When researchers conduct follow-ups at multiple intervals, they need to report their data with and without non-completers and
with and without the last observation carried forward. Researchers also need to be cautious in the way they summarize follow-up
findings in abstracts and reviews. If they follow up only completers or responders, this needs to be clearly stated in the summarizing
follow-up findings in the abstract.
• The timeframe patients are asked to consider in follow-up assessment is also important. The most sensible course may be for
researchers to assess both the immediate past (e.g., symptoms in the past month) as well as the entire period since termination or
the last follow-up assessment.
SELECTING AN APPROPRIATE DESIGN: RCTS AND THEIR ALTERNATIVES
WHEN RCT DESIGNS ARE USEFUL
• Two conditions in which RCT designs are useful:
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1. The symptoms or syndromes that least violate the assumptions of EST methodology involve a link between a specific stimulus or
representation and a specific cognitive, affective, or behavioral response that is not densely interconnected with (or can be
readily disrupted despite) other symptoms or personality characteristics (simple phobia, specific social phobia, panic symptoms,
obsessive-compulsive symptoms, PTSD following a single traumatic experience).
- Symptoms that involve generalized affect states, in contrast, violate virtually all the assumptions of EST methodology
- With respect to treatments, those that readily lend themselves to paramedic variation (and hence to genuine
dismantling) and to the degree of within-condition standardization required for causal inference in RCTs are least likely
to violate the assumptions of EST methodology
- The studies that have yielded the best results in the psychotherapy literature are those that have targeted syndromes that
least violate the assumptions regarding comorbidity and personality inherent in EST methods, applying treatments
that least violate the requisites of experimental design as applied in EST methodology
2. Researchers can still make considerable use of RCT designs to assess specific intervention strategies or principles, general
approaches to treatment, and moderators of outcome.
- Investigators might address the more modest goal of testing whether a specific intervention strategy is associated with a
clinically significant reduction in depressed mood, and if so, for how long
- A focus on testing specific interventions allows researchers to move more quickly from main effects to clinically
meaningful questions
- The goal is to isolate intervention strategies that clinicians can integrate into their practice when working with a patient
for whom depression is a prominent symptom
• Perhaps one of the most important uses of RCTs would be to establish, empirically, the length of a given treatment required to
produce a clinically meaningful response, a relatively enduring change, and so forth, vis-à-vis a particular set of outcome variables.
ALTERNATIVES TO RCT DESIGNS
• A transactional approach: there is a need to reconsider the top-down, unidirectional model of science and practice that has
become increasingly prevalent in recent years, which assumes that knowledge flows primarily from researchers to clinicians. As a
field, however, we might be better served by a more transactional philosophy of clinical science, in which the laboratory and the
clinic are both seen as resources for hypothesis generation and testing, albeit with different strengths and limitations.
• The reality is that many, if not most, of the major clinical innovations in the history of our field have come from clinical practice.
• One way of selecting treatment strategies more systematically is to use clinical practice as a natural laboratory.
INTERACTIVE LECTURE 1
SEVERE AND PERSISTANT MENTAL ILLNESS (SPMI)
The National Institute of Mental Health (1987) defined SPMI using the following criteria:
a. A major diagnosis of non-organic psychosis or personality disorder
b. Duration of at least 2 years
c. At least three of the five categories of functional disabilities
• Diagnosis = a major affective, non-organic psychotic disorder or a disorder that may lead to a chronic disability such as BPD.
• Duration = treatment history meets one or both of the following criteria:
1. Has undergone psychiatric treatment more intensive than outpatient care more than once in a lifetime (e.g., crisis response services,
alternative home care, partial hospitalization, or inpatient hospitalization).
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2. Has experienced an episode of continuous, supportive residential care, other than hospitalization, for a period long enough to have
significantly disrupted the normal living situation.
• Disability = severe recurrent disability resulting from mental illness, the disability results in functional limitations in major
life activities. Individuals must meet at least two of the following criteria on a continuing or intermittent basis:
1. Is unemployed, is employed in a sheltered setting or supportive work situation, or has markedly limited skills and a poor work
history.
2. Requires public financial assistance from out-of-hospital maintenance and may be unable to procure such assistance without
help.
3. Has difficulty in establishing or maintaining a personal social support system.
4. Requires help in basic living skills such as hygiene, food preparation, or money management.
5. Exhibits inappropriate social behavior which results in intervention by the mental and/or judicial system.
THE SIDDD DIMENSIONS OF A DEFINITION OF SEVERE MENTAL ILLNESS
“DIFFICULT TO TREAT PATIENTS”
• (Urban) contextual factors:

- Poverty (dept)
- Low social-economic status
- Unemployment
- Homelessness
- Criminal/inappropriate social behavior
• Dual diagnosis:
- In combination with substance abuse
- Childhood trauma, childhood abuse, attachment problems
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- Depressive or anxiety symptoms
PERSPECTIVE ON SPMI
“For much of the 20th century, severe mental illness was considered chronic and deteriorating, requiring institutional tertiary care
or high-intensity secondary care. This approach changed in the 1960s with the advent of anti-psychotic drugs and subsequent
deinstitutionalization, which gave new hope to patients with severe mental illness who were discharged into the community.”
FROM CARE TO CURE
DEFINITIONS
• Ontology = state/way of being, what we assume the world is like.

- With cancer we can look into the body and see the cause of it (e.g., a tumor)
- With psychology it is a bit more difficult to touch and grasp what a psychiatric disorder is and what the cause of it is (it is
vaguer and more complex)
• Epistemology = how we can know/understand/describe reality.
- “If we want to understand disorders we have to describe symptoms as clearly as possible”
• Nomothetic approach = regular, lawful approach.
- Is after universal laws, things that go for everyone
- Very big in the medical world
• Idiographic approach = looks to the individual.
- Dimensional, developmental, subjective, gradual
- Diagnosis in context: diagnosis is not an explanation but an understanding and it has to have a utility
- More holistic approach: interaction and person-oriented
- Variation and change in individuals
- Effects of specific interventions (key moments)
- The therapist and the patient as individual persons and their interactions
NOMOTHETIC APPROACH
Severe mental illness implies medical discourse of cure and drug-based treatment.
• Nomothetic approach = explanation of symptoms by underlying diseases.
- Focus on universal/lawful disease states
- When person X has disease Y, the disease will cause symptoms x, y, and z
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CURE IN PSYCHIATRY (NOMOTHETIC)
• Ontology = disease model ® underlying cause

- Symptoms = observable signs of the underlying cause
- Treatment goal = eliminate cause
- Treatment outcome monitoring = observe reduction of symptoms or signs or elimination of cause
- End result = no more symptoms = no more disease
• Epistemology = describe symptoms as clearly as possible
- Cookbook psychiatry: list of ingredients that are needed (= how we use the DSM at the moment)
- Comorbidity: problem for DSM because in order to be certain that a specific treatment works, we have to isolate diagnoses
in research but in practice comorbidity is highly prevalent!
• Evidence-based treatments
- Efficiency and dose-response = “for this diagnosis you’ll be cured in 16 sessions”
- Manualization = “for people with a specific disorder, this specific treatment in this specific order will be effective”
- Responsibility is at professionals’ side
- Objective evidence is impersonal = it doesn’t matter who the therapist is, it will always work
THE SYMPTOM-REDUCTION MODEL
• Evidence-based treatment focused on symptom reduction.

• Hyperfocus on diagnosis in diagnosis-disability-duration.
• Assumption of malleability of symptoms.
1. Linear
2. Causal
3. Predictable
4. Protocolled
5. Stepped care
DSM PITFALLS
• High comorbidity rates.

• Many disorders occur dimensionally rather than categorically (cut-off).
• Diagnostic categories are highly heterogeneous (e.g., 256 ways to diagnose BPD based on five out of nine criteria).
• Limited predictive validity of diagnoses regarding treatment process and outcome.
• The category Not Otherwise Specified (NOS) often yields large numbers but lacks clarity.
“SAVING NORMAL”
• Weak scientific status

1. Classification is not ontology
2. Reliability: old wine in new barrels
• Diagnostic inflation
1. Overdiagnosis/overtreatment of mild problems
2. Large impact on concept of sickness
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3. Undertreatment of complex problems

• Superior Health Council Belgium (2019):
1. SMI = messy, complex, multidimensional, contextual
2. Psychiatrists and psychological diagnostician: don’t limit your view to DSM! (See The Lancet, 2019)
• “The pampering and dithering era for people with SMI”.
ALTERNATIVES
• Research Domain Criteria (RDoC), network- and transdiagnostic dimensions.

- Dimensional, multi-level, developmental
- Doesn’t isolate but looks at all dimensions and focuses on whole picture (holistic)
- Ontology = internal system interacts with external systems (same as DSM ontology)
- Epistemology = look into it in a more holistic way (differs from DSM epistemology)
- Transdiagnostic dimensions (no fixed term)
- No comorbidity issues
- More about action
- Focuses on more severe syndromes
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• Nomothetic versus idiosyncratic, holistic.

• Interactional and person-oriented approaches.
WHY RESEARCH DOMAIN CRITERIA (RDOC)?
• Symptom-based diagnosis faces several problems:

- Heterogeneity: people with same symptom-based diagnoses may share limited number of symptoms
- Comorbidity: several isolated disorders or underlying mental health dimensions?
- Research eligibility: research selects participants with ‘pure’ disorders and excludes variation and combination as
‘messiness’
- Arbitrary cut-offs: symptom count for diagnosis creates arbitrary groups of ‘disorder’ versus ‘healthy’
• RDoC = dimensional, multi-level, developmental.
• Domain = unit of analysis

- Negative valence = responsible for a response to a negative situation or context, such as fear and loss
- Positive valence = responsible for a response to a positive situation or context, such as joy
- Cognitive systems
- Systems for social processes
- Arousal/regulatory systems = responsible for sleep and wake, and the energy balance
“DSM-5 is a guidebook by the American Psychiatric Association on how to diagnose mental disorders. It has many critics, including
the National Institute of Mental Health (NIMH), which in response produced an alternative model (RDoC) to guide research efforts.
However, this approach has also been controversial, as it focuses heavily on neurobiology and much less on investigating issues
that are important for everyday psychiatric care, such as symptoms and illness course.” (Kotov et al., 2017)
NOMOTHETIC VERSUS IDIOSYNCRATIC, HOLISTIC
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• Between-group differences exaggerated, within-group minimalized (Slade, 2009; Westen, Novotny, & Thompson-Brenner, 2004)
® problem nomothetic approach.
“Symptoms arise either from intensification of subjective experiences or behaviors that have been present for some time or from
acquisition of new experiences or behaviors, or most frequently from a combination of both.”
• Dimensional, gradual, subjective ® idiosyncratic course and circumstances.
DIAGNOSIS IN CONTEXT
• Slade: diagnosis is not an explanation but an understanding ® does not reveal truth, but describes a lived reality.
• “Diagnosis is classification with utility” (Kendell & Jablensky, 2003) ® has to fit lived realities.
• Holistic approach: interactional and person-oriented (Upshur, Vandenkerkhof, Van Goel, 2001).
PERSON-ORIENTED APPROACH (LUNDH & FALEKNSTRÖM, 2019)
• Variation and change in individual patients.

• Effects of specific interventions (key moments).
• The therapist and patient as individual persons, and their interactions.
FROM CARE TO CURE BACK TO CARE
• We talk a lot about patients with severe mental illness:

- With a focus on what is wrong
- Aimed at diagnosis and differentiation
- For the goal of efficient and cost-effective treatment
• But we fail to talk with them, to assess their understanding, ideas for recovery, their strengths.
• Slade: “Avoidance of illness is a clinical preoccupation, and has a short-term horizon. Development of well-being is a long-
term process, and involves different tasks”.
• Illness narratives as starting point and goal:
- See: De Verhalenbank Psychiatrie
- Next week: interview expert-by-experience
THEME 2
LITERATURE
NOLEN-HOEKSEMA – CHAPTER 8: SCHIZOPHRENIA SPECTRUM AND OTHER PSYCHOTIC DISORDERS
• Psychotic = when experiences and beliefs are out of touch with reality.
• The symptoms that make up schizophrenia can appear in mild to moderate form in many people who do not meet full criteria for
any disorder (so it lies on a continuum).
• The continuum of schizophrenia spectrum and other psychotic disorders:
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- Schizotypal personality disorder = moderate symptoms resembling those of schizophrenia but with a retained grasp
on reality, often speak in odd and eccentric ways, have unusual beliefs or perceptions, and have difficulty relating to other
people
- Delusional disorder = individuals have persistent beliefs that are contrary to reality, but they lack other symptoms of
schizophrenia and often are not impaired in their functioning (delusions tend to be about things that are possible but
untrue)
- Brief psychotic disorder = individuals have symptoms of schizophrenia for 1 month or less
- Schizophreniform disorder = individuals have symptoms of schizophrenia for 1 to 6 months but usually resume their
normal lives
- Schizoaffective disorder = mixed picture of schizophrenia and major depression or mania
- Other psychotic disorders, including substance-induced psychotic disorder and psychotic (or catatonic) disorder
associated with another medical condition, are psychoses specifically brought on by a substance or an illness, respectively
and they may be short-term or longer lasting
• If you are unable to tell the difference between what is real and what is unreal, you are experiencing psychosis.
• Psychosis can take many forms, and one of the most severe and puzzling psychotic disorders is schizophrenia.
• At times, people with schizophrenia think and communicate clearly, have an accurate view of reality, and function well in daily life.
At other times, during the active phase of their illness, their thinking and speech are disorganized, they lose touch with
reality, and they have difficulty caring for themselves.
• Most people who develop psychotic disorders do so in their late teenage or early adult years, when they are ready to begin
contributing to society.
• Within the US, 1-2% of the population will develop schizophrenia at some time in their lives.
• The majority of people with schizophrenia live independently or with their family.
• There are almost as many people with schizophrenia in jails, prisons, and homeless shelters and on the street as there are in
hospitals and nursing homes.
SYMPTOMS, DIAGNOSIS, AND COURSE
• DSM-5 refers to the schizophrenia spectrum to reflect the fact that there are five domains of symptoms that define psychotic
disorders, and their number, severity, and duration distinguish psychotic disorders from each other.
• Positive symptoms:
- Delusions
- Hallucinations
- Disorganized thought (speech)
- Disorganized or abnormal motor behavior (inc. catatonia)
• Negative symptoms:
- Restricted emotional expression or affect
• People with schizophrenia also often show numerous cognitive deficits that research has shown are linked to declines in
functioning, although cognitive symptoms are not part of the diagnostic criteria.
POSITIVE SYMPTOMS
Described as positive because they are overt expressions of unusual perceptions, thoughts, and behaviors.
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• Delusions = ideas that an individual believes are true but that are highly unlikely and often simply impossible. It differs from self-
deceptions in three ways:
1. Self-deceptions are at least possible, whereas delusions often are not.
2. People harboring self-deceptions may think about these beliefs occasionally, but people harboring delusions tend to be
preoccupied with them.
3. People holding self-deceptions typically acknowledge that their beliefs may be wrong, but people holding delusions
often are highly resistant to contradicting arguments or compelling facts.
Name Definition Example

Persecutory delusion False belief that oneself or one’s loved ones Belief that the CIA, FBI, and local police are
are being persecuted, watched, or conspiring to catch you in a sting operation
conspired against by others
Delusion of reference Belief that everyday events, objects, or Belief that a newscaster is reporting on your
other people have an unusual personal movements, or that a random manhole cover was
significance put there so you could see it
Grandiose delusions False beliefs that one has great power, Belief that you are Martin Luther King, Jr.,
knowledge, or talent or that one is a reincarnated
famous and powerful person
Delusions of being Belief that one’s thoughts, feelings, or Belief that an alien has taken over your body and is
controlled behaviors are being imposed or controlled controlling your behavior
by an external force
Thought broadcasting Belief that one’s thoughts are being Belief that your thoughts are being transmitted via
broadcasted from one’s mind for others to the Internet against your will
hear
Thought insertion Belief that another person or object is Belief that your spouse is inserting blasphemous
inserting thoughts into one’s mind thoughts into your mind
Thought withdrawal Belief that thoughts are being removed Belief that your roommate is stealing all your
from one’s mind by another person or by thoughts while you sleep
an object
Delusion of guilt or False belief that one has committed a Belief that you have killed someone or that you are
sin terrible act or is responsible for a terrible responsible for a disaster (e.g., flood)
event
Somatic delusion False belief that one’s appearance or part of Belief that your intestines have been replaced by
one’s body is diseased or altered snakes
- Delusions also occur in other disorders, such as people with severe forms of depression or bipolar disorder having
delusions that are consistent with their moods (when they are depressed, they might believe that they have committed
some unforgivable sin, and when they are manic, they might believe that they are a deity).
- Although the types of delusions above likely occur in all cultures, the specific content of delusions can differ across
cultures. These differences probably reflect differences in the culture’s belief systems as well as differences in the
people’s environments.
• Hallucinations = unreal perceptual experiences.

- Hallucinations of people with schizophrenia tend to be more frequent, persistent, complex, sometimes more bizarre, and
often entwined with delusions
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- Can involve any of the senses: auditory (e.g., hearing voices, most common), visual (2nd most common), tactile
(something is happening to the outside of the body), and somatic (something is happening inside the body)
hallucinations
• Disorganized thought and speech = often referred to as formal thought disorder.

- One of the most common forms of disorganization in schizophrenia is a tendency to slip from one topic to a
seemingly unrelated topic with little coherent transition, often referred to as loose associations or derailment:
Ø Word salad = speech is so disorganized as to be totally incoherent to the listener
Ø Neologisms = person makes up words that mean something only to him/her
Ø Clangs = associations between words based on the sounds of the words rather than on the content
Ø Repeating the same word or statement over and over again
- Men with schizophrenia tend to show more severe deficits in language than do women with schizophrenia, possibly
because language is controlled more bilaterally – that is, by both sides of the brain – in women than in men
• Disorganized or catatonic behavior = unpredictable and apparently untriggered agitation – suddenly shouting, swearing, or
pacing rapidly.
- Trouble organizing their daily routines of bathing, dressing properly and eating regularly
- Because their attention and memory are impaired, it takes all their concentration to accomplish even one simple task,
such as brushing their teeth
- They may engage in socially unacceptable behavior
- Catatonia = disorganized behavior that reflects unresponsiveness to the environment – ranges from a lack of response
to instructions (negativism), to showing a rigid, inappropriate, or bizarre posture, to a complete lack of verbal or motor
responses (e.g., mutism)
- In catatonic excitement, the person shows purposeless and excessive motor activity for no apparent reason
NEGATIVE SYMPTOMS
Specific psychotic symptoms are labeled negative symptoms because they involve the loss of certain qualities of the person, rather
than behaviors or thoughts that the person expresses overtly. Furthermore, the presence of negative symptoms is more associated
with poor outcome than is the presence of strong positive symptoms, in part because the negative symptoms tend to be persistent
and more difficult to treat.
• Restricted affect = a severe reduction in or absence of emotional expression.

- Fewer facial expressions of emotions
- May avoid eye contact
- Less likely to use gestures to communicate emotional information than people without the disorder
- Tone of voice may be flat, with little change in emphasis, intonation, rhythm, tempo, or loudness to indicate emotion or
social engagement
- Self-report questionnaire often find that people with schizophrenia report significant anhedonia, or a loss of the ability
to experience pleasures, but they may be experiencing emotion that they cannot express
• Avolition = inability to initiate or persist at common, goal-directive activities, including those at work, at school, and at home.
- Physically slowed down in movements
- Seems unmotivated
• Asociality = lack of desire to interact with other people.
- Avolition may be expressed as asociality
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- Individuals with schizophrenia are often withdrawn and socially isolated
COGNITIVE DEFICITS
People with schizophrenia show deficits in basic cognitive processes, including attention, memory, and processing speed.
• These deficits taken together may contribute to the hallucinations, delusions, disorganized thought and behavior, and avolition of
people with schizophrenia.
• The immediate relatives of people with schizophrenia also show many of these cognitive deficits to a less severe degree, even if they
do not show the symptoms of schizophrenia.
• Cognitive deficits may be an early marker of risk for schizophrenia and may contribute to the development of other symptoms
and strongly contribute to the disability of the illness.
DIAGNOSIS
A. Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully
treated). At least one of these must be 1, 2, or 3:
- Delusions
- Hallucinations
- Disorganized speech (i.e., frequent derailment or incoherence)
- Grossly disorganized or catatonic behavior
- Negative symptoms (i.e., diminished emotional expression or avolition)
B. For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major areas, such as
work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset (or when the onset is in childhood
or adolescence, there is failure to achieve expected level of interpersonal, academic, or occupational functioning).
C. Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms
(or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or
residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative
symptoms or by two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual
experiences).
D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either (1) no major
depressive or manic episodes have occurred concurrently with the active-phase symptoms, or (2) if mood episodes have occurred
during active-phase symptoms, they have been present for a minority of the active and residual periods of the illness.
E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical
condition.
F. If there is a history of autism spectrum disorder or communication disorder of childhood onset, the additional diagnosis of
schizophrenia is made only if prominent delusions or hallucinations in addition to the other required symptoms of schizophrenia
are also present for at least 1 month (or less if successfully treated).
Specify if:
With catatonia
• Difficulties in functioning are tied to the negative symptoms of schizophrenia – the lack of motivation and appropriate
emotional responding – as well as to the positive symptoms.
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• People with schizophrenia who show many negative symptoms have lower levels of educational attainment and less success holding
jobs, poorer performance on cognitive tasks, and a poorer prognosis than do those with predominantly positive symptoms.
• The negative symptoms are less responsive to medication than are the positive symptoms.
PROGNOSIS
• The life expectancy of people with schizophrenia is between 10 and 20 years shorter than that of people without schizophrenia.
• Between 5% and 10% of people with schizophrenia commit suicide, with the highest rates among those recently diagnosed or
experiencing a first psychotic episode.
• Many people with schizophrenia do not show a progressive deterioration in functioning across the life span but instead stabilize
within 5-10 years of their first episode, showing few or no relapses and regaining a moderately good level of functioning.
GENDER AND AGE FACTORS
• Women with schizophrenia tend to have a better prognosis than men with the disorder.
• Women diagnosed with schizophrenia tend to have better prior histories than men (which may be, in part, because the onset
of schizophrenia in women tends to be in the late twenties or early thirties, whereas men more often develop schizophrenia in their
late teens or early twenties).
• Women with schizophrenia show fewer cognitive deficits than men with the disorder.
• Estrogen may affect the regulation of dopamine, a neurotransmitter implicated in schizophrenia, in ways that are protective for
women.
• In both men and women, functioning seems to improve with age. Perhaps they find treatments that help them stabilize, or
maybe they and their families learn to recognize the early symptoms of a relapse and seek earlier treatment before the symptoms
become acute. Alternatively, the aging of the brain might somehow reduce the likelihood of new episodes of schizophrenia.
SOCIOCULTURAL FACTORS
• Schizophrenia tends to have a more benign (goedaardig) course in developing countries than in developed countries. The social
environment of people with schizophrenia in developing countries may facilitate adaptation and recovery better than the social
environment of people with schizophrenia in developed countries.
SCHIZOAFFECTIVE DISORDER
Schizoaffective disorder is a mix of schizophrenia and a mood disorder. People with schizoaffective disorder simultaneously
experience psychotic symptoms (delusions, hallucinations, disorganized speech and behavior, and/or negative symptoms) and
prominent mood symptoms meeting the criteria for a major depressive or manic episode.
DIAGNOSIS
A. An uninterrupted period of illness during which there is a major mood episode (major depressive or manic) current with
Criterion A of schizophrenia. Note: The major depressive episode must include Criterion A1: Depressed mood.
B. Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode (depressive or manic) during the lifetime
duration of the illness.
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C. Symptoms that meet criteria for a major mood episode are present for the majority of the total duration of the active and residual
portions of the illness.
D. The disturbance is not attributable to the effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.
Specify type:
Bipolar type: A manic episode is part of the presentation. Major depressive episodes may also occur.
Depressive type: If only major depressive episodes are part of the presentation.
Specify if:
With catatonia
SCHIZOPHRENIFORM DISORDER
Schizophreniform disorder is quite the same as schizophrenia, but with symptoms that last only 1 to 6 months (intermediate
between brief psychotic disorder and schizophrenia).
DIAGNOSIS
A. Criteria A, D, and E of Schizophrenia are met.

B. An episode of the disorder lasts at least 1 month but less than 6 months. When the diagnosis must be made without waiting
for recovery, it should be qualified as "provisional."
Specify if:
With good prognostic features: as evidenced by two or more of the following:
1. Onset of prominent psychotic symptoms within 4 weeks of the first noticeable change in usual behavior or functioning
2. Confusion or perplexity
3. Good premorbid social and occupational functioning
4. Absence of blunted or flat affect
Without good prognostic features
With catatonia
BRIEF PSYCHOTIC DISORDER
Individuals with brief psychotic disorder show a sudden onset of delusions, hallucinations, disorganized speech, and/or
disorganized behavior. However, the episode lasts only for 1 day to 1 month, after which the symptoms completely remit.
Symptoms sometimes emerge after a major stressor, such as being in an accident. At other times, no stressor is apparent.
DIAGNOSIS
A. Presence of one (or more) of the following symptoms. At least one of these must be (1), (2), or (3):
1. Delusions
2. Hallucinations
3. Disorganized speech (e.g., frequent derailment or incoherence)
4. Grossly disorganized or catatonic behavior
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Note: Do not include a symptom if it is a culturally sanctioned response.

B. Duration of an episode of the disturbance is at least 1 day but less than 1 month, with eventual full return to premorbid level
of functioning.
C. The disturbance is not better explained by major depressive or bipolar disorder with psychotic features or another psychotic disorder
such as schizophrenia or catatonia, and is not attributable to the physiological effects of a substance (e.g., substance of abuse, a
medication) or another medical condition.
Specify if:
With marked stressor(s) (brief reactive psychosis): if symptoms occur in response to events that, singly or together, would be
markedly stressful to almost anyone in similar circumstances in the individual's culture.
Without marked stressor(s): if symptoms do not occur in response to events that, singly or together, would be markedly stressful to
almost anyone in similar circumstances in the individual's culture.
With postpartum onset: if onset is during pregnancy or within 4 weeks postpartum
With catatonia
DELUSIONAL DISORDER
Individuals with delusional disorder have delusions lasting at least 1 month regarding situations that occur in real life, such
as being followed, being poisoned, being deceived by a spouse, or having a disease. Unlike schizophrenia, they do not show any
other psychotic symptoms. Other than the behaviors that may follow from their delusions, they do not act oddly or have difficulty
functioning. It appears to affect females more than males. Onset tends to be later in life than most disorder, with an average age
of first admission to a psychiatric facility of 40 to 49 years.
DIAGNOSIS
A. The presence of one (or more) delusions with a duration of 1 month or longer.
B. Criterion A of schizophrenia has never been met. Note: Hallucinations, if present, are not prominent and are related to the delusional
theme (e.g., the sensation of being infested with insects associated with delusions of infestation).
C. Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired, and behavior is not
obviously bizarre or odd.
D. If manic or major depressive episodes have occurred, these have been brief relative to the duration of the delusional periods.
E. The disturbance is not attributable to the physiological effects of a substance or another medical condition and is not better
explained by another mental disorder, such as body dysmorphic disorder or obsessive-compulsive disorder.
Specify whether:
Erotomanic type: The central theme of the delusion is that another person is in love with the individual.
Grandiose type: The central theme of the delusion is the conviction of having some great (but unrecognized) talent or insight or
having made some important discovery.
Jealous type: The central theme of the delusion is that one's spouse or lover is unfaithful.
Persecutory type: The central theme of the delusion is the belief that one is being conspired against, cheated, spied on, followed,
poisoned or drugged, maliciously maligned, harassed, or obstructed in the pursuit of long-term goals.
Somatic type: The central theme of the delusion involves bodily functions or sensations.
Mixed type: No one delusional theme predominates.
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Unspecified type: The dominant delusional belief cannot be clearly determined or is not described in the specific types (e.g.,
referential delusions without a prominent persecutory or grandiose theme).
Specify if:
With bizarre content: If delusions are clearly implausible, not understandable, and not derived from ordinary life experiences
(e.g., delusional belief that one's internal organs have been removed by a stranger and replaced with someone else's organs without
leaving any wounds or scares).
SCHIZOTYPAL PERSONALITY DISORDER
People with schizotypal personality disorder have a lifelong pattern of significant oddicities in their self-concept, their
thinking and behavior. They do not have a strong and independent sense of self and may have trouble setting realistic or clear
goals. Their emotional expression may be restricted, as in schizophrenia, or odd for the circumstances. They may have few close
relationships and trouble understanding the behaviors of others.
DIAGNOSIS
A. A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships
as well as by cognitive or perceptual distortions and eccentricities of behavior, beginning by early adulthood and present in a variety
of contexts, as indicated by five or more of the following:
1. Ideas of reference (excluding delusions of reference).
2. Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g.,
superstitiousness, belief in clairvoyance, telepathy, or "sixth sense"; in children and adolescents, bizarre fantasies or
preoccupations).
3. Unusual perceptual experiences, including bodily illusions.
4. Odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped).
5. Suspiciousness or paranoid ideation.
6. Inappropriate or constricted affect.
7. Behavior or appearance that is odd, eccentric, or peculiar.
8. Lack of close friends or confidants other than first-degree relatives.
9. Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather
than negative judgments about self.
B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features,
another psychotic disorder, or autism spectrum disorder.
Note: If criteria are met prior to the onset of schizophrenia, add "premorbid", e.g., "schizotypal personality disorder (premorbid)."
BIOLOGICAL THEORIES
GENETIC CONTRIBUTORS TO SCHIZOPHRENIA
• Family, twin, and adoption studies all indicate the presence of a genetic component to the transmission of schizophrenia (see
Figure 2).
• A home with a parent with schizophrenia is likely to be stressful. When a parent is psychotic, the child may be exposed to illogical
thought, mood swings, and chaotic behavior.
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• The biological relatives of adoptees with schizophrenia were 10 times more likely to have a diagnosis of schizophrenia than were
the biological relatives of adoptees who did not have schizophrenia. In contrast, the adoptive relatives of adoptees with
schizophrenia showed no increased risk for the disorder. This points to genes having a greater contribution to the risk for
schizophrenia than environment.
• 83% of the variation in schizophrenia is due to genetic factors. Even when a person carries a genetic risk for schizophrenia,
however, many other biological and environmental factors may influence whether and how he/she manifests the disorder.
STRUCTURAL AND FUNCTIONAL BRAIN ABNORMALITIES
• The most consistent finding is a gross reduction in gray matter in the cortex of people with schizophrenia, particularly in the
medial, temporal, superior temporal, and prefrontal areas.
- Aberrations in the normal development of the prefrontal cortex during mid- to late adolescence may help explain the
emergence of the disorder during this period
- The hippocampus, which plays a critical role in the formulation of long-term memories, is another brain area that
consistently differs from the norm in people with schizophrenia
• The brains of people with schizophrenia show reductions and abnormalities in white matter (material that forms the connections
between areas of the brain), particularly in areas associated with working memory.
- These abnormalities are present in individuals before they develop overt symptoms of schizophrenia, suggesting that
they are early signs of the disorder rather than consequences of the disease process
- White-matter abnormalities can impair the ability of various brain areas to work together, which could lead to the severe
deficits seen in schizophrenia
• People with schizophrenia also show enlarged ventricles (fluid-filled spaces in the brain), suggesting atrophy, or deterioration,
in other brain tissue. People with schizophrenia with enlarged ventricles tend to show social, emotional, and behavioral deficits
long before they develop the core symptoms of schizophrenia. They also tend to have more severe symptoms than other people
with schizophrenia and are less responsive to medication.
DAMAGE TO THE DEVELOPING BRAIN
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• Birth complications: serious prenatal and birth difficulties are more frequent in the histories of people with schizophrenia than
in those of people without schizophrenia and may play a role in the development of neurological difficulties.
- Perinatal hypoxia (oxygen deprivation at birth or in the few weeks before or after birth) may be especially important
- As many as 30% of people with schizophrenia have a history of perinatal hypoxia
• Prenatal viral exposure: epidemiological studies have shown high rates of schizophrenia among persons whose mothers were
exposed to viral infections while pregnant.
- Especially during the second trimester of pregnancy, which is a crucial period for the development of the CNS of the
fetus
NEUROTRANSMITTERS
• Dopamine has long been thought to play a role in schizophrenia.

• The original dopamine theory was that the symptoms of schizophrenia are caused by excess (te hoge, overmatige) levels of
dopamine in the brain, particularly in the prefrontal cortex and the limbic system
• Supported by several lines of evidence:
- Drugs that tend to reduce the symptoms of schizophrenia, the phenothiazines or neuroleptics, block the reuptake of
dopamine, reducing the functional level in the brain
- Drugs that increase the functional level of dopamine in the brain, such as amphetamines, tend to increase the incidence
of the positive symptoms of schizophrenia
- Neuroimaging studies suggest the presence of more receptors for dopamine and higher levels of dopamine in some
areas of the brain in people with schizophrenia than in people without the disorder
• The original dopamine theory of schizophrenia proved too simple. Many people with schizophrenia do not respond to the
phenothiazines. Simple dopamine depletion does not fully explain the negative symptoms.
• Kenneth Davis et al. (1991) proposed a revised theory suggesting that different types of dopamine receptors and different levels
of dopamine in various areas of the brain can account for the symptoms of schizophrenia:
1. Excess dopamine activity in the mesolimbic pathway (involved in salience and reward).
- Abnormal functioning in this area of the brain may lead individuals to attribute salience to otherwise innocuous stimuli,
contributing to hallucinations and delusions and to deficits in motivation
- The atypical antipsychotics may work to reduce the symptoms of schizophrenia by binding to a specific type of
dopamine receptor common in the mesolimbic pathway, blocking the action of dopamine
2. There may be unusually low dopamine activity in the prefrontal areas of the brain (involved in attention, motivation,
and the organization of behavior).
- This may lead to the negative symptoms of schizophrenia: lack of motivation, inability to care for oneself in daily functions,
and the restriction of affect
• Other neurotransmitters also play an important role in schizophrenia:
- Serotonin neurons regulate dopamine neurons in the mesolimbic system, and some of the newest drugs for treating
schizophrenia bind to serotonin receptors
- Glutamate and GABA have abnormal levels in people with schizophrenia
PSYCHOSOCIAL PERSPECTIVES
SOCIAL DRIFT AND URBAN BIRTH
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• People with schizophrenia are more likely to experience chronically stressful circumstances, such as living in impoverished
inner-city neighborhoods and having low SES or being unemployed.
• Some research supports a social drift explanation for this link: because schizophrenia symptoms interfere with a person’s ability
to complete an education and hold a job, people with schizophrenia tend to drift downward in social class compared to the class of
their family of origin.
• Several studies have shown that people with schizophrenia and other forms of psychosis are more likely to have been born in a
large city than in a small town.
STRESS AND RELAPSE
• Stressful circumstances alone might not cause someone to develop schizophrenia, but they might trigger new episodes in people
with the disorder.
• One major stressor linked to an increased risk for episodes in schizophrenia is immigration (leaving behind extended networks
of family and friends, financial stress, language, new culture).
SCHIZOPHRENIA AND THE FAMILY
• One factor in family interaction that is associated with multiple episodes of schizophrenia is expressed emotion:
- Families high in expressed emotion are overinvolved with one another, are overprotective of the family member with
schizophrenia, and voice self-sacrificing attitudes toward the family member while at the same time being critical, hostile,
and resentful toward him/her
- Talking as if the ill family member can control his/her symptoms
- Often have ideas about how the family member can improve his/her symptoms or functioning
COGNITIVE PERSPECTIVES
• Fundamental difficulties in attention, inhibition, and adherence to the rules of communication lead people with
schizophrenia to try to conserve their limited cognitive resources. One way they do this is by using certain biases or thinking styles
for understanding the overwhelming information streaming through their brain.
• Cognitive therapies help patients identify and cope with stressful circumstances associated with the development and worsening of
symptoms.
TREATMENT
BIOLOGICAL TREATMENTS
• Typical antipsychotic drugs: phenothiazines.

- Appear to block receptors for dopamine, thereby reducing its action in the brain
- By 1971, the number of people with schizophrenia who required hospitalization had decreased to half of what would
have been expected without the use of the drugs
- About 25% of people with schizophrenia do not respond to these antipsychotic drugs
- Among people who do respond, the typical antipsychotics are more effective in treating the positive symptoms of
schizophrenia than in treating the negative symptoms
- People have to take the drug all the time in order to prevent new episodes of active symptoms
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- Lots of side-effects (such as grogginess, dry mouth, blurred vision, sexual dysfunction, weight gain or loss, depression)
• Atypical antipsychotic drugs: clozapine.
- Binds to the D4 dopamine receptor, but it also influences several other neurotransmitters, including serotonin
- Clozapine has helped many people with schizophrenia who never responded to the phenothiazines, and it appears to
reduce the negative symptoms as well as the positive symptoms in many patients
- Also lots of side-effects (such as dizziness, nausea, sedation, seizures, weight gain
PSYCHOLOGICLA AND SOCIAL TREATMENTS
• Can help individuals increase their social skills and reduce their isolation and apathy.
• Reduce the stress and conflict in their lives, thereby reducing the risk of relapse into psychosis.
• Treatments are given in addition to medication and can increase patients’ level of everyday functioning and significantly reduce
the risk of relapse.
• Cognitive treatments: helping people with schizophrenia recognize and change demoralizing attitudes that they may have
toward their illness so that they will seek help when needed and participate in society to the extent that they can.
• Behavioral treatments: based on social learning theory, include the use of operant conditioning and modeling to teach
persons with schizophrenia skills such as initiating and maintaining conversations with others, asking for help or information from
physicians, and persisting in an activity, such as cooking or cleaning.
• Social interventions: increasing contact between people with schizophrenia and supportive others, often through self-help
support groups, who discuss the impact of the disorder on their lives, the frustration of trying to make people understand their
disorder, their fear of relapse, their experiences with various medications, and other day-to-day concerns.
• Family therapy: combination of basic education on schizophrenia with the training of family members in coping with their loved
one’s inappropriate behaviors and the disorder’s impact on their lives.
- Educational: taught about the disorder’s biological causes, its symptoms, and the medications and their side-effects, with
the hope that this will reduce self-blame in family members, increase their tolerance for the uncontrollable symptoms
and allow them to monitor their family member’s use of medication and possible side-effects
- Communication skills to reduce harsh, conflictual interactions, as well as problem-solving skills to help manage
issues in the family such as lack of money, in order to reduce the overall level of stress in the family
- Specific behavioral techniques for encouraging appropriate behavior and discouraging inappropriate behavior on the
part of their family member with schizophrenia
- 24% of people who receive family-oriented therapy in addition to drug therapy, relapse into schizophrenia, compared to
64% of people who receive routine drug therapy alone.
- The interventions must be culturally sensitive!
• Assertive community treatment programs: provide comprehensive services for people with schizophrenia, relying on the
expertise of medical professionals, social workers, and psychologists to meet the variety of patients’ needs 24 hours a day.
- The home-based intervention group showed lower levels of emotional distress and of positive symptoms during
the intervention than did the control group
- The gains that people in skills-based interventions make tend to decline once the interventions end, suggesting that
these interventions need to be ongoing
• Cross-cultural treatments: traditional healers.
- The structural model says that there are interrelated levels of experience – such as body, emotion, and cognition or the
person, society, and culture – and symptoms arise when the integration of these levels is lost
Ø Healing thus involves reintegrating these levels through a change of diet or environment, the prescription of herbal
medicines, or rituals
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- The social support model holds that symptoms arise from conflictual social relationships, and healing involves
mobilizing a patient’s kin to support him/her through the crisis and reintegrating the patient into a positive social support
network
- The persuasive model suggests that rituals can transform the meaning of symptoms for patients, diminishing their
pain
- In the clinical model, the faith the patient has in the traditional healer to provide a cure for the symptom is sufficient
(placebo)
FENEKOU & GEORGACA – EXPLORING THE EXPERIENCE OF HEARING VOICES: A QUALITATIVE STUDY
INTRODUCTION
• The phenomenon of hearing voices, in psychiatric terminology “auditory hallucinations”, has been traditionally understood in
psychiatry and psychology as an inherently psychopathological phenomenon and a central symptom of schizophrenia and other
psychotic disorders.
• Hearing voices is much more common in the general population than was previously thought!
• It is not the experience of hearing voices per se that causes distress and may lead to the need for treatment, but the ways in which
the person copes with the voices he/she hears.
- The main factor determining how well a voice hearer deals with his/her voices is the belief that the person holds
regarding the voices
• There seems to be a consensus that the experience of auditory hallucinations is the result of a process of misattribution of internal
mental states, specifically inner speech, to an external source.
• A trend has emerged in the last two decades, which attempts to explain hearing voices as an experience with meaning and
significance for the people who hear them.
RESULTS
THE FUNCTION OF VOICES
• To guide and advise the voice hearer, mainly on everyday tasks and ongoing activities, such as their posture, their behavior, what
to eat and wear, etc.
• To direct them to perform activities they do not want to perform.
• To advise them regarding their treatment, mainly by giving them instructions concerning their medication.
• To mobilize them to carry out their everyday tasks, and thus encourage them to resist their tendency to inertia and passivity.
• To guide them concerning their relationships with other people: commenting on specific relationships and advising the hearer
on how the handle them, what to do or what to say when in the presence of others.
• To compliment, support, and encourage them.
• To swear at them and insult them.
• They have a supernatural character, as they foretell future events, disclose information to the hearer and inform the hearer about
the nature of the world and their mission in it.
• The function of the voices seems to be stable for each voice, and is closely linked to the voice’s identity.
• The voices that participants in this study hear seem to have positive and negative functions in a roughly equal degree.
• The hearer’s reaction towards the voices depends on the function of the voices.
- The individuals who hear voices which are neutral or positive tend to be reconciled with the fact that they hear voices
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- Some participants commented that the voices keep them company and play an important role in their lives
- Those who hear negative and unpleasant voices tend to react with negative emotions
• The participants, especially those who hear negative voices, customarily use a series of strategies to deal with them:
- Talking back to the voices through swearing at them, shouting at them and telling them to stop
- Diverting their attention through concentrating on other activities (e.g., during work)
- Treating the voices with indifference
UNDERSTANDING HEARING VOICES
• The way in which voice hearers explain the source and origin of the voices as well as the relation of the voices to reality and to their
thoughts:
- Origin of the voices in themselves
- Origin in an external source and imposed on them (linked to the sense of involuntariness)
- Both to internal and to external sources
• Explanations:
- Biological factors: brain dysfunction, heredity, mental illness, drug abuse, medication
- Psychological
- Social
• In this sample, they didn’t encounter any religious and spiritualist explanations of the voice, which seem to be common to voice
hearers. Even the few participants who heard voices with supernatural character gave biological explanations when asked about the
voices’ origin.
• The voices confuse them with regard to their sense of reality, which can take the form of being unclear about whether the voices’
claims are real and should be followed or not, and being so preoccupied with the voices that they lose contact with the environment
and withdraw.
- Confusion about whether what they hear is the voices or someone else talking to them
- Some use reality testing strategies, which voice hearers seem to customarily use, which involve either logical thought
operations or monitoring the source of the voices
• According to a few participants, thoughts may turn to voices and vice versa.
DISCUSSION
• Many of the participants welcomed the opportunity to talk about their voices and most noted that they have never spoken to anyone
about their voices so extensively before.
• The lack of attendance to the patient’s experience is the source of an overriding feeling of invalidation people with experiences of
psychosis describe. Not talking about the voices entails the danger of increasing isolation and withdrawal as well as of
developing more idiosyncratic and less socially functional ways of understanding and coping with the voices.
• This study provides one more testimony to the observation that hearing voices is a very complex phenomenon.
PRE-RECORDED LECTURE 2
EXPERT-BY-EXPERIENCE: JEROEN ZWAAL
PART 1: FIRST EXPERIENCE WITH PSYCHOSIS
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• Jeroen Zwaal was 6 years old when he got his first psychotic experience. During the night his brother (14 years) was shaking in the
bathroom and his mother was with him. They didn’t know he saw that.
• His whole life he’s been thinking “what was this experience?” and he was trying to organize his life and his family patterns from that
moment on. His brother got mental help, but the whole family was focused on him and his brother.
• Years later, his mother died (at his 15th birthday), and after that his life was broken into two worlds: before and after his mother died.
They were left with only his father, mourning, lot of work and burn-out symptoms. He got worried about his father and they got a
lot of arguments, it was really tensioned.
• At 18 years old, there was a moment when he couldn’t sleep anymore. His head was buzzing around and he could only go on when
he could understand his worries. But it was too much and too complicated. At that time, he discovered that images were helping
him and they gave him space. He got an image and he could walk around in that image.
• He told his teacher about his image (mostly with his father in it), but that was psychosis language and she couldn’t understand
that. Metaphors made more sense for him than all of the words he had in his mind. He was trying to connect with the story and
nobody understood, which gave more tension. He got out of connection (buzzy head, no more sleep, no ease) and was believing
that something was wrong with his father. He told himself that he was the normal one. He needed help but couldn’t
communicate it. There was shutting down behavior (towards the world) but his father thought he was fine.
• Duty call, he overslept. But he wanted to show them he was a normal guy. When he came there he had an interview and told
them a lot of stuff, but they didn’t recognize he was confused. He didn’t have to go into the army because he got the S5 code
(“lunatic”). But they didn’t do anything with it. And he went away with the illusion that he had another assignment for the social
army, to spread love. In the city of Groningen, he was wandering around and he had to go home but he didn’t know that. He was
talking with people a lot. He couldn’t behave in a normal social way anymore.
• Then it became worse. He didn’t know how to go home, so he just opened the door of a car and asked the person sitting inside if he
could bring him home. The person called the police. The policeman came with a horse and told him to stop and the horse stepped
on his feet. That was a trigger for him so he got normal again.
• He got home and his father and brother were sitting on the couch. He bursted and screamed and yelled and went to his bedroom,
because he couldn’t believe that they were being so normal sitting there on the couch. That was the moment his father called the
doctor and he understood that something was wrong. Before that, he was worried and he told him if he would go on like that he
would become like his older brother. This was a very scary image, the worst nightmare. His brother was in hospitals etc. instead of
comforting him, his father made it more complex by comparing him to his brother. Instead of just asking what’s happening and
being there for him.
• He put more steps forward to prove he was normal and OK. Because he knew that he was normal and his father was not. The
family constellation played quite a major role in the first experience with psychosis. He experienced crisis but didn’t know how to
place it. He was really close with his mother but he also felt her struggle with cancer. She wanted support from the family and didn’t
get it and he felt that too. All the memories are about his mother wanting dialogue and talking but it didn’t work.
• Afterwards he could blame mental health care for not preparing him how his mother would die (something with gasping). They
gave him the diagnosis of bipolar disorder, but it was trauma! Yet nobody ever asked him about his trauma’s.
• The psychotic episode started with him not sleeping anymore.
• He feels energy. Father-to-father-to-father trauma. Good thing is having his own decisions, he chose to have a psychosis in some
way. After all these ideas and being aware of something going wrong, he chose to just breathe and he was feeling a lot of energy at
night. He got himself out.
• Now they know it is trauma and breathing exercises are very good to do. He had an out-of-body experience. He lost his contact
to the ground. But in a way he chose to do so. He made his own emergency escape. Psychosis was, from the start, something good.
He was quite conscious of that. Afterwards they said it was psychosis, but he still had the feeling that he was an OK guy.
• Intuition is a big part of it.
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• His brother (at 7 years old) discovered that his father had a homosexual life and he confronted him with that, but his father told him
never to talk about it anymore. Afterwards, they could see that their father wasn’t safe for them and that he was coping in a very bad
way. He couldn’t blame him, though, because he cared for his father. And he knew that his father also couldn’t be a good father for
him. He wanted harmony for himself, but he also wants to point the spot that hurts the most. But he couldn’t do that in a good way.
For him to reach harmony, everything has to be out in the open and clear.
PART 2: FIRST ENCOUNTER WITH THE MENTAL HEALTH CARE SYSTEM
• His father called the doctor saying that his son wasn’t feeling OK, but Jeroen already didn’t trust his father, so now they became
opposites. And because he didn’t trust his father, he also didn’t trust the doctor. He ran away to his brother.
• He somehow ended up in a field of a farmer for help. But the farmer saw that he wasn’t OK and called the police. While waiting for
the police he was in a shed and the farmer gave him a blanket and he felt seen and warm. And when the police came he had to go
to the hospital and they gave him the choice of going there with the small or the big ambulance. And that made him feel seen.
So, he chose the big one (of course). And that tiny little thing helped him. Being offered a choice gave him the feeling that he was
being seen.
• Even though he was in a psychosis, he remembers every little detail. He felt very welcome when he got there because a nurse made
him some food and was nice to him. A human taking care of him. His father wanted to take care of him but he didn’t, he couldn’t.
he lacked in a way that drove him to crisis, even though he didn’t mean it like that.
• He got a lot of medication and went to an isolation cellar. None of the medication worked. That part he doesn’t really remember
because of the medication. The goal of the medication was to get his high spirit going to the ground again. It’s in one way an
emergency intervention, which is OK, according to Jeroen. What works better is people caring for you and being there with him!
• Difficulty with people saying “this is not allowed”, instead of asking why. Just always ask why!
• Questions to ask someone with psychosis:
- Where do you come from?
- What’s your problem?
- What’s your wish?
- What can I do for you?
- What’s the future you want to go to?
• Ask questions with curiosity. You are the owner of your story.
• They didn’t see him as a human, but as a patient within a system.
• First time in the hospital was the best, with lots of structured guidance and activities. After that he just got locked up and didn’t do
anything.
• Creative therapy was good, because he could work with his hands. The therapist worked on her own and he on his own project.
There was respect.
• Psychosis = so much energy, exploding.
• Jeroen felt like “if they don’t take my story serious, why should I take them serious?” and he didn’t feel treated like a human being.
Yet he accepted the way it was, because he didn’t know he needed trauma therapy.
• He could share everything with his best friend. He was open to some people, but not so much. He didn’t have an interpretation
about what happened to him.
• What he learned:
- You can’t change your father, you can only change yourself
- Finish what you started
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PART 3: TRAUMATIC HISTORY AND PERSONAL MEANING-MAKING
• A nurse mentioned it, but it was only later on that he started to recognize the role of trauma in his psychosis.
• Systemic therapy: father in therapy, therapist called his father out which was really a moment where he felt acknowledged and
heard. He also cut the relationship with his father at that point.
• In the bottom line: “you’re OK” releases a lot of tension. Being welcome, having purpose, someone who gives trust.
• He embraces his psychosis/energy now!
PART 4: RECOVERY PARADIGM
• Calibrating the real essence again, because somewhere we missed it with science. It’s all reality, look at the whole reality.
• We need science and knowledge, but we never have to make reality smaller than it is!
• We measure a lot, but we can’t assume what’s hidden in the soul.
• It’s all about the relationship! It’s about the human and human, changing by heart, rescripting each other’s scripts.
• It’s OK to have this role of psychologist/psychiatrist, but if you hide in this role instead of being human, it goes wrong.
- Do you want to help me or do you want to make money? They feel that!
COMPLEX, COMORBID, AND CHORNIC DISORDERS
CONFUSED PERSONS
Associations:
- Hallucinations
- Delusions
- Inappropriate behavior
- Anxiety
- Relational problems/lack of stable relationships (exclusion)
- Social stigma
- Homelessness
- Lack of a job/economic resources
- Lack of perspective for a better future
CONFUSED PERSONS: A GROWING PROBLEM
“Confused behavior further analyzed” (RIVM, 2016) ® more attention!

- Increase in ‘E33/E14’-codes: assigned to calls to the emergency number regarding people with confused behavior
- From the 80.000 calls in 2016, 61.000 were linked to 34.000 unique persons (so a lot of people call more than once!)
- Apparently, it’s necessary to call more than once, so we failed to help these persons the first time
- Often the first encounter into the care system is via the police, who transfer the persons to the Dutch Mental Health Care
system, the GGZ
- Confused people often don’t know that they need help, they don’t know the way to find help
- However, ‘confused persons’ often do not present with straightforward symptoms that can be addressed via a protocol
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SUPPOSED YOU THINK YOU ARE BEING FOLLOWED…
• When a patient experiences a psychotic delusion in which (s)he is followed by the police, it is highly anxiety-inducing to be
enforced by police, locked up in a psychiatric facility and put in isolation for hours or days, sometimes enforced.
• Expert-by-experience Brenda Froyen (2015): “I was not the nice patient. I fought. I bit, I screamed, I scratched. And being a mother,
whose baby is taking away and being kept from breastfeeding, I would do that again today, even now that I am not psychotic.”
• We have to try to put ourselves in the shoes of our patients to understand them better. Our response to people as professionals
is quite decisive in how people will respond to us and will accept help and efforts to offer them something.
‘DIFFICULT PATIENTS’
• ‘Difficult-to-treat’ or simply ‘difficult patients’ are people with severe mental illnesses (SMI), such as:
- Psychosis
- Non-psychotic severe depression, complex trauma or anxiety, or personality related complaints
- Dual diagnoses (often when abuse problems)
- Especially when accompanied by work-related or social-economic consequences such as homelessness or financial dept
- “Heterogeneous and fluctuating symptomatology that is not easily diagnosed, difficulty in establishing a positive
working alliance, active help seeking but ambivalent help-accepting behavior, and consistent noncompliance with
professionals’ expectations”
• Froyen (2015): “There is a big incentive to be ‘a good patient’” ® negative!
- People feel belittled, not respected, not in charge (which might trigger trauma)
- Whenever you approach people who are noncompliant, we can give a lot of positive arguments for offering them stability
but the tone of voice and hierarchy in psychiatry is very good to keep an eye on
- Psychiatry may become a threat in itself
• Often involves stigma and (professional) prejudice!
- Bias against ‘good outcome psychosis’
- Ignoring network and social resources
- Distinguishing hospitalization from follow-up care and recovery
• The context in which people live is pretty much ignored! So, strengths in their social network are ignored, where their personal
resources lay.
Expert-by-experience Wilma Boevink: “A psychosis is far-reaching and overwhelming. A psychosis involves a severe distortion of
meaning. It renders the world unfamiliar, unrecognizable, a threat. Psychosis can turn life into a living hell. Just ‘being’ can no
longer be taken for granted. Nothing can be taken for granted. A psychosis is also accompanied by a sense of estrangement.
What you have is often closely allied to who you are (as if you become the psychosis). The manifestations sometimes dominate
your entire personality.”
PSYCHOSIS AND URBAN CONTEXT
• Social drift: downward drift in social class due to inability to work or find a place in social circumstances
• Low SES as risk factor.
• Urban living as risk factor: urban risk factors itself and social environmental factors
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URBAN RISK FACTORS
• High rates of pollution (e.g., air, water).

• Noise pollution (e.g., traffic).
• Specific urban designs (e.g., tall buildings that may be perceived as oppressive).
• More physical threats (e.g., accidents, violence).
“Thereby likely increasing stress levels with negative effects on mental health. Research indicates that urban air, water, and noise
pollution can have substantial effects on the mental health of urban populations. For example, living close to major streets or
airports increases exposure to traffic noise and pollution and is associated with higher levels of stress and aggression.”
URBAN SOCIAL ENVIRONMENT FACTORS
• Concentrations of low SES (e.g., education levels, income).

• Low social capital (e.g., social support, efficacy).
• Social segregation (e.g., perceived minority status, ethnic group membership).
• Premorbid vulnerability resulting in single marital status may be more likely to progress to psychosis in an environment with a
higher perceived level of social isolation.
“Living in poverty can both contribute to and result from impairments associated with poor mental health. Social isolation and
discrimination as well as poverty in the neighborhood contribute to the mental health burden while little is known about specific
interactions between such factors and the built environment.”
• So, it can be both ways: urban factors as risk factors, but also as a result of social drift.
ENVIRONMENTAL FACTORS AND CONTEXTUALITY
• DSM-IV: categorical ® DSM-V: dimensional.

• Environmental factors:
- Social and urban context
- Socio-economic status and education
- Family- and social networks
- (Childhood) trauma: very rarely present in treatment options but very prevalent!
- Cultural discourse (spirituality)
CULTURAL DISCOURSE
• What is considered ‘erroneous beliefs’ depends on cultural context (Nolen-Hoeksema).

• Defining erroneous beliefs is very difficult, it is culturally sensitive.
• Symptoms might have meaning within context!
THE UNHELPFUL IDEA OF ERRONEOUS BELIEFS
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• “Fixed beliefs that are not amenable in the light of conflicting evidence” (DSM-V) still suggests ‘falseness’ of beliefs, which implies
the need for correction of beliefs for cure, but these beliefs are part of people’s lived reality, so recovery has to happen within this
frame of reality.
• Delusions do not simply occur as isolated beliefs within the stream of experiences. Rather, they are experiences of an already
altered sense of reality stemming from overwhelming feelings of profound anxiety and uneasiness. “If we want to get behind
these mere external characteristics into the psychological nature of delusion”, argued Jaspers, “we must distinguish the original
experience from the judgment based on it.”
• Distinction between experience and judgment! We are very obsessed with the judgment part (we judge these experiences as being
right/wrong/real/unreal), which is what we try to work on in CBT. We tell them to change their judgment.
CBT AND ERRONEOUS BELIEFS
• The fundamental assumption of CBT is that the information processing of external and internal stimuli is biased in mental
disorders, thereby causing systematic distortions of the individual’s construction of experience. These distortions consist of
cognitive errors (biases), dysfunctional beliefs and enduring maladaptive cognitive structures (schemas), where the latter two are
stored constructs (representations) of previous experiences.
• The aim of CBT as Beck once put it, is to demonstrate to a patient ‘that a particular belief is wrong or dysfunctional and that another
belief is more accurate and adaptive.’
REIFICATION
• The second strategy used by CBT for observing and measuring mental processes is reification, i.e., the reduction of mental
phenomena to object-like entities that can be defined and understood in isolation. In this sense, mental phenomena are
interpreted as independent objects with readily definable properties, akin to physical objects in the world, e.g., a chair or an
orange.
- Defining psychosis in this way = cookbook psychiatry
• Reification = understanding the world as fitting your descriptions.
- You make a subscription of the world and assume that the world is the way you describe it
- List approach vs. holistic approach
• Experience versus judgment:
- Individuals who hear voices for a long time tend to enter a stage of stabilization, whereby the voices become
integrated in the hearer’s life
- When people explain the voices biologically, this might be explained by the long-standing subjection of participants to
biomedical discourses on auditory hallucinations as part of their contact with mental health services or by the demand
characteristics of the interview
• Listen genuinely!
• Focus on (pragmatic) meaning rather than on strict empiricist observation!
• Reification: if you have a subscription about which beliefs are false, in your approach you will approach it as false and therefore not
relevant to listen to. It shapes your way of understanding the phenomena by the description you gave it.
WHAT DO THE VOICES SAY?
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• Fenekou & Georgaca (2010):

- When people hear voices, they try to make sense of them
- Just telling people that the voices they hear are erroneous is not sufficient to make sense!
• How to distinguish between ‘false’ internal voices and ‘correct’ but ingenuine voices of health care professionals?
• Phenomenology of trauma and psychosis.
- What differentiates hearing the voice of a perpetrator, hearing the voice of bully’s, and hearing other external voices?
PTSD AND COMPLEX TRAUMA
• Psychotic symptoms may occur in 15-64% of individuals with PTSD.

- Comorbidity or integrated risk factor?
• Complex trauma = prolonged and repeated harmful, dangerous, extreme events, often involving:
- Interpersonal elements: harm-doing by people to people
- Developmental disruption: childhood neglect, physical abuse, sexual abuse, and psychological abuse
- Involvement of the caregiving system or the disruption of primary attachment
• Impossibility to escape.
• The psychosis may have been true in the past (trauma)!
• Working on trauma ® help them make sense to cope!
REVICTIMIZATION: REPETITION OF TRAUMA
“In psychiatry, a distortion of reality was forced on me once more. Nobody ever asked me what had happened to me. Nobody ever
asked me: what was it that drove you mad? I was observed, diagnosed, and treated as a disturbed person, but nobody ever looked
at the association with my life history. Victims of abuse who react with psychosis will not receive recognition as such from
psychiatry – if that’s what they seek at all. Many of us entertain huge guilt complexes, and we are convinced we are to blame for the
crime of which we, in fact, are the victim. We search in numerous ways for confirmation of our guild and wickedness. We punish
ourselves in a multitude of ways. In becoming a psychiatric patient, we are supported in our belief that we are bad. As
psychiatric patients we in fact keep alive the patterns with which we are so familiar. Thus, we succeed in prolonging our victim
role. Becoming a psychiatric patient could essentially be called a repetition of trauma.” (Boevink, 2006, p.18).
LEAVE THE BIO-BIO-BIO MODEL
• “Just 20 years ago, it would have been difficult to get papers on childhood trauma and psychosis published. Mental health
professions have been slow, even resistant, to recognize the role of childhood adversities in psychiatric disorder.” (Read & Bentall,
2012).
• Relationship between childhood abuse and the actual content of hallucinations and delusions, as well as research
demonstrating that abuse disclosures by people diagnosed with schizophrenia are reliable (Read, Bentall, & Fosse, 2009).
• Psychotherapy to try to understand the personal meaning of psychosis in the context of the individual’s life ® help that individual
make meaning out of their experience (Read & Dillon, 2013).
Expert-by-experience Wilma Boevink:

“We are examined but not really seen; we are listened to but not really heard. Psychiatry does not regard us as serious discussion
partners: after all, with a disorder you cannot speak.”
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THEME 3
LITERATURE
SLADE – CHAPTER 3: WHAT IS RECOVERY?
1. CLINICAL RECOVERY
Four key features:

1. It is an outcome or a state, generally dichotomous
2. It is observable and objective (not subjective)
3. It is rated by the expert clinician, not the patient
4. The definition of recovery is invariant across individuals
• Only 11% of people with severe and enduring mental health problems remain unrecovered and deep in the system. This is much
less than the clinical rule of thirds (i.e., a third recover, a third have fluctuating course and a third will never get better) would
suggest.
• Empirical data challenge the applicability of a chronic disease model to mental illness, with its embedded assumption that
conditions like schizophrenia are necessarily life-long and have a deteriorating course.
2. PERSONAL RECOVERY
• The understanding of recovery that emerged from individual accounts has a different focus from the clinical recovery, for example
in emphasizing the centrality of hope, identity, meaning and personal responsibility.
• Opinions in the consumer literature about recovery are wide-ranging, and cannot be uniformly characterized. This multiplicity of
perspective in itself has a lesson for mental health services – no one approach works, or ‘fits’, everyone. There is no right way for a
person to recover.
• Recovery is seen as a journey into life, not an outcome to be arrived at. Recovery is not about ‘getting rid’ of problems, but about
seeing people beyond their problems – their abilities, interests and dreams – and recovering the social roles and relationships
that give life value and meaning.
• Recovery is a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills, and/or roles. It is a
way of living a satisfying, hopeful, and contributing life even within the limitations caused by illness. Recovery involves the
development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness.
• Personal recovery is an individual process, so what helps an individual at one time in their life may not help them at another. This
means that there cannot be a single recovery model for services.
Key elements of a recovery approach:

Summary description Aspects identified by Perkins and Aspects identified by Ralph
Repper
Recovery involves a journey Recovery is a continuing journey, not an Recovery is a journey from alienation to
end-product or a result a sense of meaning and purpose
from disengagement to Recovery is moving from withdrawal to
engagement, engagement and active participation in
life
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from surviving to living and Recovery is about growth Recovery is active coping rather than
growing. passive adjustment
Although awareness of the Recovery is breaking through denial
journey often starts in and achieving understanding and
adversity, such as mental acceptance
illness,
A recovery vision is not limited to a
particular theory about the nature and
causes of mental health problems
the journey is not about the Recovery is not the same as cure
adversity.
Although the journey of Recovery can, and does, occur without
recovery has many routes, professional intervention
and each person’s journey is Everyone’s recovery journey is different
unique, and deeply personal, there are no rules of
recovery, no formula for ‘success’
it often involves finding the Recovery is the reawakening of hope
courage to hope for a good after despair
future and to relate to yourself
Recovery is about taking back control over Recovery means no longer viewing
one’s own life oneself as primarily a person with a
psychiatric disorder and reclaiming a
positive sense of self
and others in beneficial ways. Recovery is not accomplished alone; the
journey involves support and
partnership
Setbacks are inevitable, but the Recovery is not a linear process Recovery is a complex and nonlinear
challenge is universal journey
Recovery is not specific to people with
mental health problems
• Personal recovery makes operationalization of the concept and empirical investigation problematic, but not impossible.
• Sandra Resnick et al. identified four domains of a recovery orientation in patients:
1. Empowerment
2. Hope and optimism
3. Knowledge
4. Life satisfaction
ARE CLINICAL RECOVERY AND PERSONAL RECOVERY INCOMPATIBLE?
• Three definitions of recovery (Ralph & Corrigan):

1. Spontaneous recovery = recovery is a naturally occurring phenomenon
2. Clinical recovery = as with other medical illnesses, people can recover from mental illness with proper treatment
3. Personal recovery = recovery reintroduces the idea of hope in understanding serious mental illness
• Mental health professionals gravitate towards the second definition (clinical recovery), whereas consumers typically find more value
in the first (spontaneous recovery) and third (personal recovery).
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• Clinical recovery is subordinate to personal recovery. Personal recovery encompasses the three types listed above, while clinical
recovery is only one of these types.
CLINICAL RECOVERY AND HOPE
• Hope leads to action based on approach rather than avoidance motivation – having positive goals, rather than trying to avoid
negative outcomes.
• Hope is a problem in mental health services, because many mental health professionals either explicitly or implicitly make
statements about the person never being able to work again, or live independently, or have children, or be treatment-free. These
statements are wrong and produce a lot of hopelessness. And hopelessness takes away the motivation to become well again.
CLINICAL RECOVERY AND MEANING
• Finding meaning in life is a central challenge for anyone. It involves making sense of experiences, and generating a story
which fits for the person. This gives a narrative of how they come to be where they are in life. Often there is a liberating aspect to
the narrative. It also provides a context and purpose for the future – it is the spring-board for hope.
• How people develop meaning:
- Life history (e.g., a difficult childhood)
- Medical, often expressed with ambivalence, such as a view of medication as a ‘necessary evil’ (with recovery as present
when medication had ceased to be an ‘issue’)
- Spiritual
- Social, especially constructing a self-narrative through telling one’s story, and negotiating or compromising on the
basis of the listener’s response
• The implication of this diversity is that imposing any single explanatory model can be damaging. It is more productive to support
the person in their quest for meaning through a stance of offering an understanding rather than imposing an explanation.
• Suffering with meaning is bearable – meaningless suffering is what drives you mad.
• Finding meaning is moving on.
CLINICAL RECOVERY AND SYMPTOMS
• For clinical recovery, symptom reduction is necessary. For personal recovery, there is no universal stance about symptoms.
• There are at least two pragmatic reasons not to view symptom reduction as the primary goal of mental health services:
1. It leads to this escalating cycle of increasing compulsion
2. A view of symptoms as always undesirable ignores the potential benefits
• Symptoms of mental illness are not always all bad, they can co-exist with high achievement, or contribute to a richness in life.
• Personal recovery is not always about symptoms, although it is almost always about the relationship with symptoms.
PERSONAL RECOVERY AND MENTAL HEALTH SERVICES
• Mental health services should be focused on the promotion of personal recovery, and not of clinical recovery.
• Five justifications:
1. Epistemological – personal recovery places more value than clinical recovery on the knowledge of the individual
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2. Ethical – acting in the professionally defined best interests of the patient should not be a primary value of mental health
services
3. Effectiveness – the most common treatment (medication) does not cure, so the central promise of a clinical recovery
approach is simply not fulfilled
4. Empowerment – ‘their’ life has not been safe in our hands
5. Policy-based – national policy requires a focus on personal recovery
SLADE – CHAPTER 9: THE PERSONAL RECOVERY FRAMEWORK
EMPIRICAL FOUNDATIONS
• The personal recovery framework is based on empirical research into the domains and stages of personal recovery.
THE DOMAINS OF PERSONAL RECOVERY
Four key domains of personal recovery:

Domain Definition Central question Importance in mental illness
1. Hope A primarily future-oriented expectation of What will happen to Mental illness and its devaluing
attaining personally valued goals, me? consequences can take away hope
relationships or spirituality which lead to for a good future
meaning and are subjectively considered
possible
2. Identity Those persistent characteristics which Who am I? Mental illness undermines
make us unique and by which we are personal and social identity
connected to the rest of the world
3. Meaning
Direct An understanding which makes adequate What has happened? Mental illness is a profound
meaning personal sense of the ‘mental illness’ experience, which requires a
experience personally satisfactory explanation
Indirect An integration of the direct meaning into What does this mean Mental illness leads to re-
meaning personal and social identity for me? evaluation of values and
personally meaningful life goals
4. Personal A constellation of values, cognitions, What can I do? The mental illness itself and
responsibility emotions and behaviors which lead to full responses from the person, mental
engagement in life health services and wider society
can all undermine the ability to be
responsible for one’s own life
The stages of personal recovery:

Stage Subscription
1. Moratorium Characterized by denial, confusion, hopelessness, identity confusion and self-protective withdrawal.
2. Awareness The first glimmer of hope for a better life, and that recovery is possible. This can emerge from within
or be triggered by a significant other, a role model or a clinician. It involves a developing awareness
of a possible self, other than that of mental patient.
3. Preparation The person resolves to start working on recovery, e.g., by taking stock of personal resources, values
and limitations, by learning about mental illness and available services, becoming involved in
groups and connecting with others who are in recovery.
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4. Rebuilding The hard work stage, involving forging a more positive identity, setting and striving towards
personally valued goals, reassessing old values, taking responsibility for managing illness and for
control of life, and showing tenacity by taking risks and suffering setbacks.
5. Growth [May also be considered the outcome of the previous recovery processes] whether or not symptom-
free, the person knows how to manage their illness and stay well. Associated characteristics are
resilience, self-confidence and optimism about the future. The sense of self is positive, and there is
a belief that the experience has made them a better person.
NIMH four-stage model of recovery:

1. Dependent/unaware
2. Dependent/aware
3. Independent/aware
4. Interdependent/aware
Non-linear development through six stages (by the Recovery Advisory Group Recovery Model):
1. Anguish – described as bottoming out
2. Awakening – a turning point
3. Insight – the beginning of hope
4. Action plan – finding a way
5. Determined commitment – to be well
6. Well-being, empowerment, recovery
Shortcomings of stage models:

• It imposes an order on human growth and development which may not fit some people’s experiences (external validity is limited).
• It can easily become seen as a model for what should happen, with consequent feelings of failure incurred for people who do not
seem to be recovering.
• Response: distinguish between a map and a route. Providing a map of the terrain does not prescribe the best way through it –
providing a synthesis of the kinds of domains and processes involved in the recovery journey of others has value in a general way,
but does not provide an individualized list of instructions to follow.
Clinical advantages:
• They contribute to therapeutic optimism.
• They provide a way of making sense both of progress and of lack of discernible progress in a non-stigmatizing and non-
pathologizing way.
• They help clinicians to become more sophisticated in providing support matched to the person’s stage of recovery, with
different sorts of action needed to support people at different stages of recovery.
IDENTITY
• Psychologists use identity as a term to describe personal identity – the things that make a person unique.
- Components include a mental model (self-image) of oneself, self-esteem (a valued personal identity) and individuation
(the process of differentiated components becoming a more indivisible whole), along with a capacity for self-reflection
and awareness of self
- That which sets us apart
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• Sociologists more commonly use the term as meaning social identity – the collection of group membership that define the
individual.
- Components include role-behavior, discrimination towards outsiders by members of the in-group, and identity
negotiation in which the person negotiates with society about the meaning and value of their identity.
- That which joins us
• Philosophers use the term as meaning persistence – the existence of a persisting entity particular to a given person.
- Components include change, time and sameness
- That which is preserved from the previous version in time when it was modified
- The recognizable individual characteristics by which a person is known
• Identity comprises those persistent characteristics which make us unique and by which we are connected to the rest of the world.
• Applying the definition of identity to mental illness, there are three component elements of an identity as someone with a mental
illness:
1. I see myself as a person with mental illness (personal identity)
2. Others relate to me, and I relate to others, as a person with mental illness (social identity)
3. Both 1 and 2 are ongoing (permanence)
• Spoiled identity or threatened identity = when a mental patient feels different because the associated social and clinical messages
reinforce this personal identity.
THE FOUR TASKS OF RECOVERY
1. DEVELOPING A POSITIVE IDENTITY
• The process of developing a positive identity outside of being a person with a mental illness involves establishing the conditions
in which it is possible to experience life as a person not an illness.
- The me-it difference: developing a positive identity involves finding the me who has the it – the mental illness
• A positive identity gives the possibility of a personally valued future, hope.
• The goal for people with mental illness is to move from an either-or stance to a both-and stance – I am a person in my own right and
I have a mental illness.
• Push-pull strategy: amplifying the sense of self and diminishing the identity as a person with mental illness.
• Relationships lie at the heart of identity. A positive identity is developed by establishing or re-establishing identity-enhancing
relationships.
NIMH framework six meanings of recovery:

1. A return to a state of wellness
2. Achievement of a personally acceptable quality of life
3. A process or period of recovering
4. A process of gaining or restoring something
5. An act of obtaining usable resources from apparently unusable sources
6. Recovering an optimum quality of life in disconnected circumstances
2. FRAMING THE ‘MENTAL ILLNESS’
• Framing involves making sense of the experience, which makes the experience comprehensible and allows for a positive future.
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• The aim is to move from the why me? point to the yes… but point.
3. SELF-MANAGING THE MENTAL ILLNESS
• Framing the mental illness experience provides a context in which it becomes one of life’s challenges, allowing the ability to self-
manage to develop.
• The goal of self-management might involve (for different people):
- Cure – getting rid of it
- Adaptation – learning ways of living with it
- Positive re-framing – finding value in it
- Minimizing – downgrading its impact on identity
- Displacing – getting on with more important things
• The key transition is from being clinically managed to taking personal responsibility through self-management. This
doesn’t mean doing everything on your own. It means being responsible for your own well-being, including seeking help and
support from others when necessary – the interdependent/aware phase.
4. DEVELOPING VALUED SOCIAL ROLES
• Differs from development of a positive identity in two ways:

1. It is about who I am to others and in the world, rather than who I am to me. The focus is on identities which are created
and maintained in the world – which will tend to be social rather than personal identities.
2. It is about the development of scaffolding that supports the positive identity, by providing a rich and layered identity in
which no one element (such as I am mentally ill) is the only element that really matters. It also creates fallback positions
to deal with identity challenge – well, if I’m not in work, at least I can do more painting.
• What is a valued social role?
- Personal value – feeling good about yourself for something even if others do not seem to value this role
- Social value – feeling good about a social status even if you do not personally see the job as very important
IDENTITY AND RELATIONSHIPS
• All four recovery tasks involve relationships, because identity involves relationships – either with ourselves (personal identity) or
with the world and other people in it (social identity).
• The first theories of identity (Erik Erikson’s theory of psychosocial development and George Kelly’s personal construct theory)
emphasize the importance of social interaction in negotiating and defining a sense of identity.
• Identity is not a fixed construct, but consists of a configuration of possible selves or self-constructs.
• Key possible selves are:
- The feared self – the self we are afraid of becoming
- The ideal self – the self we would like to become
• Findings from identity research:
1. The primacy and influence of these various past, present, and future selves is influenced by social interactions.
Identities can change, and are influenced by the social environment.
2. The ideal or hoped-for self is a key motivator for action and change. Focusing on strengths and hoped-for selves is
more likely to foster positive affect, future orientation and change than focusing on deficits and feared-for selves.
• Relationships are central to identity development for two reasons:
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1. They provide the context in which different possible selves emerge and are reinforced or constrained.
2. They provide a means of fostering change through focusing on hoped-for rather than feared-for identities.
• Four types of relationships:
1. Relationships with a higher being (e.g., spirituality) or connection with others (e.g., culture, society)
2. Close relationships (with partner, spouse, family, friends, neighbors, pets)
3. Relationships with other mental health service users
4. Relationship with a specific mental health professional
THE PERSONAL RECOVERY FRAMEWORK
• Four recovery tasks have been identified:

1. Developing a positive identity
2. Framing the ‘mental illness’
3. Self-managing the mental illness
4. Developing valued social roles
• These recovery tasks and the central importance of relationships inform a framework for personal recovery.
• The framework is consistent with the four key domains of personal recovery:
1. Hope
2. Identity
3. Meaning
4. Personal responsibility
• These processes are based on the insights derived from stage models that there are characteristic transitions experienced by
people in recovery.
OTHER FRAMEWORKS
• The RECOVER framework (Mental Health Commission in New Zealand):

1. Reading, researching and learning from others about mental health – learning to recognize the signs of ill health
2. Emotional growth
3. Change of circumstances – change of residence, making a new commitment to employment or further education, new
family responsibilities
4. Others – experiencing social support
5. Virtues – practicing good general health practices, avoiding known triggers and stressors, recognizing warning signs of
impending mental health problems and taking preventive action, using medication thoughtfully, emotional release,
psychological/cognitive techniques to overcome thoughts and behavior symptomatic of ill health, spiritual practices,
pushing at limitations
6. Etcetera – individual strategies, e.g., money
7. Repeat strategies that work and realize that recovery takes time
- The RECOVER framework is consistent with the personal recovery framework – it emphasizes self-management, growth
through the sustained development of a positive personal and social identity, and the importance of supportive
relationships.
• Seven naturalistic factors which impact on recovery (David Whitwell):
1. Time
2. Relationships
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3. Life events
4. Employment
5. Shock (something which jolts the person out of the mindset of identity as a person with a mental illness)
6. Development of new interests
7. Access to money and housing
- This is compatible with the personal recovery framework, because it emphasizes that recovery happens in stages, arises
from an interplay between the person and their environment, and that relationships and the ability to access normal
social resources are crucial
THE JOB OF MENTAL HEALTH PROFESSIONALS
• Four groups of support tasks:

1. The task of supporting hope – by fostering relationships and improve social inclusion
2. The task of supporting identity – by promoting well-being and goal-planning which encourages personal growth and
development
3. The task of supporting meaning – by using the assessment process to support the person to find their own meaning in
their experiences
4. The task of supporting personal responsibility – treatment matters, and offering evidence-based interventions which
foster self-management is often a vital contribution to recovery
VAN OS ET AL. – THE EVIDENCE-BASED GROUP-LEVEL SYMPTOM-REDUCTION MODEL AS THE

ORGANIZING PRINCIPLE FOR MENTAL HEALTH CARE: TIME FOR CHANGE?
MAIN POINTS OF THE ARTICLE
• Mental difficulties represent highly variable clusters of trans-syndromal symptom dimensions that defy detailed diagnostic
reduction. Use of 10-15 broad syndromes may be sufficient for daily practice.
• The model of ‘specialist’ care in diagnostic silos may be less useful than a model of applying professional skills in a trans-syndromal
fashion.
• User knowledge describes the prime importance of working on the process of strengthening resilience in the social (e.g.,
connectedness, social resources) and the existential (e.g., meaning, identity, sense of purpose) domain, rather than symptom
reduction per se.
• The context of the mental health service contributes to clinical change, in the form of a ‘general service effect’, suggesting the
importance of setting and design.
• Critical analysis of professional knowledge indicates that specialist ‘evidence-based practice’ effects may be overly attributed to the
technical (the ‘what’) rather than the relational/ritual components (the how) of treatment.
• The importance of the ‘how’ of treatment suggests the need for enhanced research and training on the set of skills and principles
mediating relational/ritual effects.
• The scale of mental health service is important in relation to the need for integration with social, medical and addiction care at the
clinical, service and public health levels.
• Development of traditional mental health services needs to go hand in hand with the development of a public mental health system,
the backbone of which may be formed by a number of complementary e-communities.
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INTRODUCTION
• According to the group-level symptom-reduction principle as applied in mental health care, mental suffering comes in the
form of universally diagnosable mental disorders which are of bio-psycho-social origin and can be classified on the basis of
symptoms.
• Within the diagnosis-EBP symptom-reduction perspective, the task of mental health services is to ‘deliver’ specialized
treatment that should be made available to those who need them, regardless of whether the setting is ‘inpatient’, ‘outpatient’, or
‘community’ treatment.
THE ADVENT OF TRANS-SYNDROMAL FORMULATIONS OF PSCYHOPATHOLOGY AND BEYOND
• The use of 10-15 broad and overlapping ‘umbrella’ syndromes may be sufficient for daily practice.
• The perceived value of diagnostic specialization is driven, in part, by the possibility of delineation of homogeneous groups in
terms of psychopathology, treatment response and prognosis. However, patients with a diagnosis of major depression are
heterogeneous in terms of symptoms, treatment response and prognosis, and show high levels of overlap with patients with
other diagnosis in terms of symptoms, treatment response and prognosis.
• A patient-centered trans-syndromal framework that flexibly combines categorial, dimensional and network approaches may
better serve the purpose of maximizing usefulness for different aspects of clinical practice.
• In order to constructively deal with this issue, the DSM-5 project attempted to introduce the notion of trans-syndromal dimensions
across the different chapters, which would have opened the way to a new form of trans-syndromal clinical practice and research.
Unfortunately, the project proved too complex and only resulted in some trans-syndromal dimensions being included in one of the
appendixes.
• It may be productive to develop a trans-syndromal framework of mental suffering that not only revolves around symptoms, but also
focuses on aspects of behavior, functioning, psychological traits, somatic factors, social factors and environmental exposures,
depending on clinical diagnostic relevance and user preference.
SERVICE AND RELATIONAL EFFECTS AS ‘INVISIBLE’ COMPONENTS OF TREATMENT
• One of the factors underlying the weak effects of psychotherapy and antidepressants as compared to placebo is the issue of
expectations, which evidence suggests may be one of the key elements driving change in states of mental ill-health. This may
explain why, despite much research and debate, there is no meta-analytic evidence that well-researched psychological treatments
for common disorders like depression, anxiety, post-traumatic stress disorder and borderline personality disorder show clear and
clinically relevant differences from each other in effect size, regardless of the level of complexity or underlying anthropological
rationale. Instead, meta-analyses reveal the same (small) effects across different treatment approaches (dodo bird hypothesis).
• While some specific differences between treatments may exist in low-prevalence subareas of mental health, for example
in anorexia nervosa and obsessive-compulsive disorder, findings more often point to equivalence within and between
pharmacological and non-pharmacological treatment approaches for common mental disorders.
• This may be suggestive of underlying heterogeneity, in the sense of some people responding only to treatment A and others
only to treatment B, and all research populations representing a mix of these two and other types. But no reliable markers of such
heterogeneity in response have been identified, despite much research.
• A stronger case can be made for a second explanation of apparent equivalence, i.e., that it is not only the specific treatment itself
(the ‘what’), but also the generic aspects of treatment (the ‘how’) which impacts outcome. Research suggests that two aspects
of the context of treatment may be important:
1. A general background service-level effect
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2. A patient-clinician relational effect at the level of the therapeutic ritual
SERVICE-LEVEL CONTEXTUAL EFFECTS
• Meta-analyses have shown that the placebo response in trials of pharmacological treatments has risen over time.
- One of the factors that may contribute to the rise in placebo response is the change in trial context and design: if the
standard care context amounts to relative ‘neglect’ by poorly developed services, placebo effects will approach natural
course, and be lower compared to placebo effects in the context of well-developed supportive services, confounding
comparisons between time periods and countries
• The same contextual issue regarding the role of standard care may impact trends in psychotherapy research over time, given meta-
analytic evidence that the efficacy of psychotherapeutic treatments like CBT has become progressively smaller over time.
- This is likely related to early trials more often including a ‘waitlist’ comparison – amounting to a comparison with natural
course – whereas later trials more often included a more active comparison treatment
• These temporal effects are important, as they appear to suggest that having interactions with an active mental health service
brings about improvement in the same way as specific treatments do.
PATIENT-CLINICIAN LEVEL CONTEXTUAL EFFECTS
• In conditions such as depression, effects do not appear to differ between treatment approaches, whereas they do vary as a function
of the specific patient-clinician mix. This observation has inspired an ongoing debate on the degree to which common factors
contribute to the observed phenomenon of equivalence of treatments.
• Common factors have to do with non-specific relational and ritual elements in the encounter between patient and clinician,
such as offering an explanatory model, proposing a theory of change, raising expectations, and inspiring patient engagement, all
within the context of a productive therapeutic relationship characterized by empathy, an active and caring attitude, and the
capacity to motivate, collaborate and facilitate emotional expression.
- This proposition is supported by research showing that a ‘relationally warm’ treatment works better than a ‘cold’
treatment and by studies documenting that pharmacological and non-pharmacological approaches reinforce each other
in the sense of their combined effect being additive, at least in depression and anxiety disorders.
THE RELATIVE DISCONNECT OF DIAGNOSIS-EBP SYMPTOM-REDUCTION INTERVENTIONS
• Diagnosis-EBP symptom-reduction interventions, if they are available at all, are typically delivered by professionals who work in
relative dissociation from the existential, social and medical needs of the patient. Most importantly, existential needs such as
loneliness, meaningless and hopelessness are not addressed.
INTEGRATION WITH USER KNOWLEDGE AND A FOCUS ON EXISTENTIAL VALUE
• The diagnosis-EBP symptom-reduction perspective was developed in the context of a bio-psycho-social model of mental health
difficulties. Several novel developments suggest that this model requires extension with an existential component, thus
reinventing itself as a bio-psycho-social-existential framework in which the existential component is central.
- The concept of ‘health’ as absence of disease is risky, as it may result in ‘too much medicine, too little care’: restoration
of health is not the goal, but rather the means to enable that patient to find and pursue meaningful goals
- Patient existential values are becoming central to the practice of a novel ‘era 3’ of evidence-informed rather than
evidence-based medicine
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- Values associated with the existential recovery perspective are connectedness, empowerment, identity, meaning,
hope and optimism, all reflecting the work of reinventing and reintegrating oneself and one’s life after experiencing
the existential crisis that comes with mental illness
• The diagnosis-EBP model and the existential domain are complementary from a treatment perspective, as the former has its focus
on the psychometric outcome of symptom reduction and the latter on the person process of resilience.
- Working on resilience means a focus on things like being connected to other people, narrative development, positive
emotions, sense of purpose, material resources and acceptance, requiring novel service initiatives such as ‘recovery
college’, structural peer support, ‘housing first’, ‘individual placement and support’, and ‘open dialog’, which can be
difficult to implement in traditional mental health services
INTEGRATION OF MENTAL, MEDICAL, SUBSTANCE USE, AND SOCIAL CARE
• Perhaps the most persistent unresolved need for people with complex mental health difficulties is the lack of alignment between
social and medical care on the other hand, and mental health care and addiction services on the other.
• People with severe mental health difficulties are more likely to experience a complex social situation characterized by poverty, social
isolation, exclusion, unemployment, stigma and housing needs.
• Optimal management involves collaboration between complex bureaucracies managing separate budgets, giving rise to a range
of barriers.
• Integration of social and mental health care can focus on the creation of recovery-oriented social enterprises as a key
component of the integrated service.
• A small-scale area might work best.
• Public health: e-communities are not diagnosis-specific, but vary in their initial presentation so as to offer people choice in seeking
help for what is most compatible with their experience.
CONSEQUENCES FOR MENTAL HEALTH SERVICES
• While the diagnosis-EBP symptom-reduction model has been productive, there is evidence that it is less than optimally connected
to patient primary needs in the social and existential domains. Thus, the larger question may be how an effort can be organized
to make mental health services more relevant to those who need them, and more in line with a critical analysis of scientific and
experiential knowledge.
• The primary process of narrative development and finding and realizing meaningful goals should be supported by treatments
aimed at trans-syndromal symptom reduction, specifically tailored to strengthen the primary process of recovery and
participation, and applied by professionals who have been trained to embrace ideography and to maximize effects mediated by
the therapeutic relationship and aspects of the care ritual.
• Education would be organized as person-centered, self-directed, practice-based and inter-professional interaction between
clients, students of different professions, and different mental health professionals, to ensure adequate development of attitudes,
knowledge and skills in collaborating, communicating and relating to each other.
GULOKSUZ & VAN OS – THE SLOW DEATH OF THE CONCEPT OF SCHIZOPHRENIA AND THE PAINFUL
BIRTH OF THE PSYCHOSIS SPECTRUM
INTRODUCTION
• Ever since its conception, schizophrenia has been an essentially contested concept.
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• Debates at mental health conferences end with around 50% in favor of abandoning the term, and 50% in favor of the status quo.
THE DEVOLUTION OF THE CONCEPT OF SCHIZOPHRENIA
• Kraepelin first conceptualized dementia praecox and manic-depressive psychosis as two distinct natural disease entities. He defined
it as a progressive deterioration to dementia and early onset.
• Bleuler later introduced the term ‘schizophrenia’ for the first time. He adopted a much broader approach that expanded the
boundaries of schizophrenia to incorporate a continuum phenotype from latent schizotypy and schizophrenia.
THE OUTCOME BIAS
• Evidence suggests that the schizophrenia construct is subject to Berkson’s bias, which is a specific type of selection bias that
occurs when the research sample is limited to help-seeking populations, particularly when the research is carried out at specialized
tertiary centers.
- The restrictive contrast of schizophrenia, particularly emphasizing chronicity and deterioration, filters out less severe
cases with good prognosis and leads to morbidity concentration
- This ‘enriched’ sample of severely ill patients with poor outcome represents only a fraction of the broader phenotype that
includes a variety of psychosis spectrum diagnostic categories such as schizophreniform disorder, delusional disorder,
brief psychotic disorder and so on
- The biased cluster of diagnosed help-seeking patients shares similarities that are discretely associated with poor outcome
but are not necessarily expressed across the whole phenotypic spectrum
• Findings indicate that the narrow definition of schizophrenia is significantly associated with a decline in the rates of patients with
a favorable outcome.
• Meta-analyses report that male sex is associated with a 1.3-1.5-fold increase in the risk of schizophrenia. Similar to the outcome
bias, the sex difference in incidence rates were significantly higher in studies with samples collected in the post-DSM-III era
compared with those collected prior to 1980 – apparently as a result of the use of more stringent diagnostic criteria. The ebb of
male preponderance in prevalence estimates, contrasting with comparable incidence rates, could be interpreted with two
propositions:
1. Male sex predicts both development of schizophrenia and either better outcome or greater illness-related mortality
during the course. However, evidence indicates no sex-difference in standardized mortality ratios and better outcome in
women diagnosed with schizophrenia.
2. Clinicians, guided by diagnostic manuals with rigid criteria, erroneously tend to overdiagnose schizophrenia in males at
first contact.
• The aim of this discussion is not to disentangle this paradox but to prompt researchers about how different definitions can
dramatically influence even basic demographic and epidemiologic parameters underlying a disease concept.
PSYCHOSIS CONTINUUM
• Modern classification systems, embracing a polythetic approach, categorize schizophrenia and related disorders on different
combinations of a required number of symptom domains that exceed the operational threshold of severity.
• Studies favoring a categorical construct over a single distribution model were heavily influenced by a variety of
methodological issues endangering the external and internal validity.
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• Psychosis expression is not an all-or-non-phenomenon, but, in fact, phenomenologically and temporally continuous across
the general population. Psychotic experiences at a subclinical level in adolescence and early adulthood have some predictive
value for psychotic disorders and also, to a lesser extent, for non-psychotic disorders, but mainly for a more severe psychopathology:
functional impairment, violence and suicide.
• Psychotic experiences are generally transient (voorbijgaand, vergankelijk). However, the likelihood of later psychopathology
that requires professional care increases as a function of the additive interaction between subthreshold expression of multiple
psychotic symptom domains – for example, the co-occurrence of hallucinations and delusions predicts higher psychopathology load
and greater severity.
- Similarly, the greater admixture with affective disturbance or motivational impairments, the greater the risk of
psychotic disorder in the future. The presence of psychosis can thus be considered as a marker for more severe
psychopathology that negatively impacts outcome.
• Studies have shown that genetic liability and exposure to environmental risk factors (trauma, urban environment, cannabis, etc.)
synergistically increase psychosis expression – as a function of the severity of comorbid psychopathology – in a dose-response
fashion and further predicts subsequent persistence and need for care in those with baseline subthreshold psychotic experience.
• The liability-threshold model provides a basis to predict phenotypic outcome quantitatively by the cumulative risk load of
genetic and environmental factors, which might be advantageous in investigating psychosis expression lying on the same
continuum with normality.
TRANSDIAGNOSTIC PSYCHOSIS MANIFESTATION
• Clinical data suggest that bipolar disorder and schizophrenia lie at distant ends of a severity continuum, with schizoaffective
being in the middle.
• Epidemiological data further show that affective dysregulation and psychosis expression, with greater exposure to
environmental risk factors, interact with each other, giving rise to a more severe outcome.
• Mounting evidence suggests that a transdiagnostic dimensional approach, complementary to the clinical utility of the
categorical approach, may provide in-depth information that covers different aspects of psychopathology beyond the borders of the
modern operationalized criteria.
SCHIZOPHRENIA IS AN OBSTACLE TO ASPIRATIONAL WORK OF EARLY INTERVENTION
• Schizophrenia diagnosis has ensured a high reliability, but its validity is debatable. Over the years, the weak validity and
specificity of the schizophrenia construct have arisen as a critical methodological issue.
• Early treatment of psychopathology (including treatment of subtle psychotic experiences), in states of anxiety/depression/drug use
with a degree of psychosis admixture will naturally improve outcome; it does not seem necessary or valid, however, to claim that
this effort represents ‘prevention of schizophrenia’.
THE TERM ‘SCHIZOPHRENIA’
• The dark view of the current concept of schizophrenia – a distinct, genetic brain disease with a poor course – is also a key factor that
further increases stigma and discrimination.
• However, even more important than stigma may be internalized negative expectations associated with schizophrenia and its
pessimistic and unproven (!) ‘devastating genetic brain disease’ description in the scientific literature.
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• The question is to what degree mental health professionals, influenced by a long tradition of pessimistic and mystifying ‘schizo’
formulations of psychotic illness, provide an environment where patients are met with hope and optimism.
FROM RARE MENTAL DISORDER (SCHIZOPHRENIA) TO PSYCHOSIS SPECTRUM DISORDERS:

DIMENSIONAL ASSESSMENT AND MULTIFACTORIAL STAGING SYSTEM
• Like all other things, the way we think about mental illness is subject to a set of shared beliefs that can show change over time
as a result of, for example, novel scientific insights or persistent calls for change from subgroups with deviant beliefs. In the area of
mental health, the shared belief that mental distress comes as diagnosable discrete entities increasingly is co-existing with a view
that mental suffering in reality represents a series of spectrum phenotypes.
• Psychotic phenomena might well be conceptualized as a broad spectrum ranging from mild but persistent schizotypy to severe
and recurrent schizophrenia.
• Current health care practice demands clinicians to make quick decisions under pressure. Therefore, the primary concern with
the multidimensional psychosis spectrum approach is whether it will be beneficial or burdensome in the hectic routine of clinical
practice. An additional obstacle is the general lack of data verifying its applicability to clinical settings.
• Diagnostic switches are common because diagnostic classification often relies on a snapshot of psychopathology, which in
reality varies over time.
• The flexible and integrated spectrum approach, employing a staging system for clinical practice and a multidimensional
structure for research use, may provide us with the essential framework to elucidate these enmeshed issues giving rise to often
frustrating heterogeneity.
• Instead of repeating the mistakes by proposing a radical shift towards a new framework offering unwarranted promises, we can
modestly start with following the footsteps of the reconceptualization of autism spectrum disorder: a single umbrella disorder –
psychosis spectrum disorder (PSD) – with specifiers. The term ‘schizophrenia’ should be abolished.
RECOVERY PARADIGM
“We will definitely see her back” (Brenda Froyen)

- To give up on someone and tell someone there is no hope…
“Hope is central to personal recovery. But hope is a problem in mental health services. The possibility of a good future is rarely
communicated by mental health professionals. This lack of hope has toxic consequences. The self-fulfilling nature of being told
by an expert that you’ll never be able to work, or live independently, or have children, or be treatment-free is profoundly damaging.
The reason that clinicians should never make these statements (either explicitly or – more common – implicitly) is not some vague
notion of withholding damaging information. It is because these statements are often wrong.” (Slade)
POSITIVE OUTCOME BIAS
• There are lots of people who actually recover from psychosis and don’t fall back.
- Positive outcome psychosis (Goluksuz & Van Os, 2017)
- Scientific bias: people who have positive outcome won’t show up in research
- This keeps us from seeing that there is actually plenty of room for people to recovery
• Myth: symptom reduction is not possible (Harding & Zahniser, 1994):
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1. Once a schizophrenic, always a schizophrenia ® heterogeneity in outcome

2. Homogeneous diagnostic category ® diagnostic diversity
3. Life-long medication use ® 25-50% can come off meds
• Recovery > cure and symptom reduction (Harding & Zahniser, 1994):
4. Don’t bother with psychotherapy ® experiential integration
- In order to make sense of their experiences, psychotherapy is very helpful, even though it may not completely fit in the
cure paradigm, it is still very important
5. Wasn’t discussed
6. Low-level jobs if jobs at all ® limitations by stigma
- Stigma limits people to enter the job market, instead of them having had a psychosis (or incompetence)
7. Families cause schizophrenia (bio/psycho) ® critical collaborators
- Family receives blame, but is also most important network
- Approaching/interacting with and including families is very important
• Recovery is not only “about symptoms, but about the relationship with the symptoms” (Slade, 2009).
• The way that people make sense of their symptoms in their life.
‘FOUNDING FATHER’ ANTHONY
• Four domains affected by SMI (severe mental illness):

1. Impairment – any loss or abnormality of psychological, physiological, or anatomical structure or function (e.g.,
hallucinations, delusions, depression)
2. Dysfunction – any restriction or lack of ability to perform an activity or task in the manner or within the range
considered normal for a human being (e.g., lack of work adjustment skills, social skills, ADL skills)
3. Disability – any restriction or lack of ability to perform a role in the manner or within the range considered normal for a
human being (e.g., unemployment, homelessness) (NOT NECESSARILY)
4. Disadvantage – a lack of opportunity for an individual that limits or prevents the performance of an activity or the
fulfilment of a role that is normal (depending on age, sex, social, cultural factors) for that individual (e.g., discrimination
and poverty)
• Medical discourse focused on impairment (Slade):
- Typified by avoidance motivation – the motivation to prevent symptoms (focus on impairment)
- Too little emphasis on approach motivation – motivation on meaningful future (focus on dysfunction, disability, and
disadvantage) ® positive psychology
MEDICAL MODEL TERMINOLOGY (CARTER, 2003; WAMPFOLD, 2001)
• States of illness = complaints experienced by the patient (e.g., pain, itching, loss of mobile functions).
- Symptoms that are most disturbing to them
• Disease = the cause of states of illness (ontological state or mechanism, often on biological level).
• Symptoms = the observable effects or manifestations of the disease.
- Not necessarily the same as states of illness
- When you’re talking to clients, you’re talking to states of illness, not to symptoms!
• Cure = reverse the condition by eliminating the difference making symptoms.
- When we want to reverse the difference making symptoms, we are talking about what we as health care professionals
take as difference making symptoms
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- E.g., in schizophrenia, we take the hallucinations as difference making symptoms, but this is not to say that for the person
these hallucinations are in fact experienced as the difference making symptoms!
EXPERIENCED CONSEQUENCES OF MEDICAL DISCOURSE
• Your experience as a disease:

1. Society condemns your experience by labelling it as ‘abnormal’ or ‘deviant’ (stigmatization)
2. You condemn your own experiences (self-stigmatization)
• The doctor is expert in your disease:
3. You are detached from your own experiences
4. You become dependent to the other
5. You lose control over your life
6. You adhere to your patient role
• Recovery means to be cured from your disease:
7. You survive despite your disease; no cure implies no recovery
8. You cannot further develop as a person
• Psychiatric focus on impairment puts focus on internal organization of the individual (Anthony, 1993):
- Ignores embeddedness of complaints in external circumstances (not just in you, also in context)
- Overlooks strengths and helpful aspects in circumstances for recovery
“The assumption that treatment involves the clinician doing something to the patient constrains possible solutions” (Slade)
- You strip people of their agency!
PRINCIPLES OF RECOVERY (ANTHONY, 1993)
1. Recovery can occur without professional intervention

2. Presence of people who believe in and stand by the person in need of recovery
3. A recovery vision is not a function of one’s theory about the cause of mental illness … people can recover even though the physical
nature of the illness is unchanged or even worsened
4. Recovery can occur even though symptoms reoccur
- “Individuals who hear voices for a long time tend to enter a stage of stabilization, whereby the voices become integrated
in the hearer’s life” (Fenekou & Georgaca, 2009)
5. Recovery changes the frequency and duration of symptoms
6. Recovery does not feel like a linear process
- Recovery is a dynamic process involving familial and social network, work and societal perspective (beyond stigma and
prejudice), agency and dynamic growth, a sense of self (identity) beyond the disease, autonomy and independence of
health care services
- “I recovered from three psychoses, mostly because I put an effort in my job” (TEDx talk Jeroen Zwaal, 2018)
7. Recovery from the consequences of the illness is sometimes more difficult than recovering from the illness itself (dysfunction,
disability, disadvantage)
- “People in recovery are not necessarily defined as persons whose psychiatric symptoms have decreased or disappeared
(clinical recovery) but rather as individuals who despite the presence of symptoms can reconstruct a positive sense of
identity and a meaningful life (personal recovery)
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8. Recovery does not mean that one was not mentally ill
MEDICAL VERSUS RECOVERY PERSPECTIVES
Medical perspective Personal recovery perspective

Your experiences are a disease (objectivity) Your experiences are not wrong but meaningful, personal,
and worthy to be known (subjectivity)
The doctor is expert in your disease (generalizable) You are the expert on your experiences and you can and are
allowed to take the lead over you own life (unique)
Recovery means to be cured from your disease (malleable) Recovery means to develop new meaning and goals, at your
own pace, beyond (mental) suffering (organic)
“Recovery is a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills, and/or roles. It
is a way of living a satisfying, hopeful, and contributing life even within the limitations caused by illness. Recovery involves the
development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness.” (Anthony,
1993)
FOUR KEY PROCESSES IN PERSONAL RECOVERY (SLADE, 2009)
1. Hope – future-oriented perspective on a meaningful life

2. Identity – develop personal identity beyond mental illness (me-it difference)
3. Meaning – making sense of ‘mental illness’ and integrate in personal meaning framework (direct and indirect meaning)
4. Personal responsibility – stay in the driver’s seat (self-management, case-based treatment planning, shared decision making)
SHARED DECISION MAKING
• Difference in perception between patients and health care professionals (Drivenes et al., 2020).
• To regard the patient as equal in the patient-clinician dynamic and decision-making processes is a medical-ethical imperative for
good practice (Goldenberg, 2013). This is an interpretative rather than just a humanistic imperative:
- Humanist approach: clinician takes the patient’s perspective into consideration and then applies a certain approach or
decision to the patient
- Interpretative approach: does not prioritize one interpretation over the other
• SDM as dynamic between professional and patient, with varying leadership roles (Brown & Salmon, 2018).
• The professional-patient dynamic is a narrative context (Greenhalgh, 1999).
PSYCHOSIS AND RECOVERY
“We revealed a dysfunctional system that does not deliver the quality of treatment needed for recovery. Is this tolerable in the 21st
century?” (The Abandoned Illness, Schizophrenia Commission)
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MENTAL HEALTH CARE: HYPERPROFESSIONALISM AND HYPERSPECIALIZATION
• Organized delivery of treatments according to the diagnosis-EBP-guideline-symptom-reduction-routine-outcome-monitoring

model of care.
THE PRINCIPLE OF MENTAL HEALTH CARE
• Diagnosis: I, the expert, know what is the matter with you.

• EBP guideline: my research knows what treatment works best for you.
• Proof of symptom reduction: my instruments measure if you got any ‘better’.
DOMINANT RESEARCH PARADIGM
“Schizophrenia is a devastating, highly heritable brain disorder.”

• We have it under control, we can study it.
• Always this underlying assumption underneath research!
• Pessimistic! “Once the symptoms of schizophrenia occur (usually in young adulthood), they persist for the entire lifetime of the
patient and are almost totally disabling,” (Science, 2002)
• Why?
RECOVERY
• “I think the main characteristics of recovery is overcoming the psychiatric diagnosis (and its effects)” (Boevink, 2002).
• The user community (recipients) start to speak up about the effects this has had on them in their illness process and they convey us
a message that this perspective has major effects on their lives and doesn’t help their recovery.
PHILOSOPHICALLY PROBLEMATIC: EPISTEMIC INJUSTICE
• Epistemic injustice = unfairness related to knowledge (the idea that we can be unfairly discriminated against in our capacity as
a knower based on prejudices about the speaker).
- Something that occurs when the science actually has developed language to help people who suffer, but that language
isn’t matching the suffering and is having effects such that the sufferer isn’t heard because the concepts and language
aren’t compatible with the suffering.
- Hearing voices (traumatic past) ® schizophrenia because they match criteria
- Hearing voices is a symptom caused by schizophrenia (clinically: appropriation – taking away the meaningful symptom
of the patient, not examining the context and its significance and relation to the life course of the patient, and repackage
it as a genetic brain disease)
- Ellen Francis
- Core problem of psychiatric diagnosis: it can cause epistemic injustice because you don’t hear the patient
DSM-5 PSYCHOSIS WORKGROUP
• Not able to change anything meaningful…
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• Psychosis susceptibility syndrome = every human being has a certain degree of psychosis susceptibility, but some people find it
difficult to deal with that susceptibility and get psychotic experiences.
• Insurances need diagnostic categories…
PSYCHOSIS SPECTRUM
• Lots of different categories, but it is actually the same disease, it is a spectrum.

• Schizophrenia prevalence is 1%.
• Overall prevalence of psychosis is 3.5%.
• Schizophrenia is a disease without specific symptoms, causes/correlates, outcomes and treatment (response).
- This is actually the science!
• Schizophrenia is just a word to remind us that within the spectrum 1/3rd has a poor prognosis on average, but even within the
diagnosis schizophrenia, there is wild variability in prognosis.
- Uncertainty is the rule
• We don’t see the science, because we’re obsessed with the symptoms.
- The science is messy!
JAPAN: IATROGENIC STIGMA REDUCTION
• In 2002, the term “mind-splitting disease” changed at request of patients’ families from a Kraepelinian to “integration
dysregulation syndrome”.
• Results in 2006:
- Uptake: 78%
- Pts informed on Dx: 37% ® 70%
- 86% psychiatrists thought more useful to inform pts
• The terminology is completely alienating (you don’t belong here ® order to commit suicide).
BIOLOGICAL PROOF OF (BRAIN) ‘DISORDER’?
• Kapur, Philips & Insel, Mol Psychiatry, 2012:

- We haven’t found any diagnostic test for any mental disorder
- Successful in neurology, but no mental disorder has had a biological correlate found!
THE BRAIN-EXPERIENCE CONUNDRUM
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• Our mental life is not in the physical domain, it’s not measurable, it’s completely subjective.
• We don’t know how they hang together!
• What they say:
- Brain activity ® mental activity
- Abnormal brain activity ® abnormal mental activity
• But there is also an influence from mind to brain!
• Mental causation: irritable ® anxious ® depressed ® paranoid.
- A mental phenomenon can cause another mental phenomenon
- Mind causes mind just as well as brain causes mind
- We ignore the hard problem of consciousness and that it’s not possible to measure it in the physical domain ® very
bad hypotheses about psychopathology
META-SCIENCE
• Meta-research has shown that most of the research we do (particularly in psychology and psychiatry) is CRAP!
• Neuroimaging is a house of cards; most studies are just wrong and never replicated.
- Only in 2020 (30 years after people started using this), shown that there is massive variation and that no two images
are the same
• Genetic risk is broadly distributed.
- We can measure genetics
- There are genetic signals in schizophrenia that are on average more common in schizophrenia than in normal controls
- If people collaborate on worldwide scale, then you get scientific findings!
- Patients on average have a higher polygenic score than normal controls, but we all have thousands of genetic variances
- The genetics of schizophrenia are the genetic of being human
- We all have psychosis in our genes!
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• Schizophrenia is a trait, a susceptibility, that we all have.
WHY DO WE HAVE A BRAIN AND GENES?
• We have a brain and genes to react to the environment.

• There is variation in how we react to the environment.
SCHIZOPHRENIA AS A SOCIAL DISORDER
• Very powerful evidence that it’s associated with urban environments, childhood trauma, migration, cannabis use.
• As much or more a social disorder than a brain disorder, so let’s stop talking about this genetic brain disorder.
IMPACT SOCIAL FACTORS ON COGNITION
• Poverty impedes cognitive function.

• Cognition isn’t hyper-biological, it’s also dependent on environment.
• Most of the mental suffering is reducible to social factors, social inequality, which is made invisible because of scientific inequality.
- It has received only 1% of funding
- Example of epistemic injustice
MEDICINE AND HEALTH CARE MOVING INTO THE 3 RD ERA
• Era 1: professional dominance.

• Era 2: accountability and market theory
• Era 3: the moral era.
- Using our humanity
- Meaning
Modern medicine: values-dialogue

Primary problem Secondary
problem
Professional-led Cure Care
Person-led Heal Deal
Working together!
MORAL ERA: ADDING VALUE
• Values dialogue:
- Listen to what the person is saying and not be influenced by bias
- Still having wonder and interest in the other person!
- Sense of professionalism and clinical reasoning that allows you to make a judgment about how a treatment can add
to the patient’s life (meaning)
• Deliberate practice.
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TREATMENT: EVIDENCE-BASED PRACTICE?
• It is a movement in crisis, particularly regarding mental health care.

• The problem in mental health care: people with the same diagnosis don’t have much in common (much more heterogeneity than
homogeneity) and response to treatment is extremely heterogeneous.
- Group-based doesn’t translate well to individual
- One size doesn’t fit all!
STOCHASTICITY
• Ultraviolet rays increase mutation rates in micro-organisms, but you can never predict whether a certain cell will undergo
mutagenesis under irradiation, and if so, which exact gene(s) will be affected. These events are random, i.e., stochastic.
- You can never predict it!
WITHIN- AND BETWEEN-PERSON ASSOCIATIONS
• Based on between-person comparisons of group A and group B, but you never know whether that’s going to have an effect at the
within-level.
• Within-group outcome can be completely different from the between-group outcome!
- This particularly applies to mental health
- One person can have a strong within-person association, but another can have a negative association and at the group
level there is weak association
MORE TREATMENT > TREATMENT TYPE
• All treatments have the same weak effect size = dodo effect.
• All treatments ‘work’.
• All treatments have mechanisms in common that work.
• What is it that these treatments work? And can we learn how to do that?
WHAT CAUSES THE TREATMENT EFFECT?
• We think there are three elements: professional, treatment method, patients.

- Professional and treatment method are very important and the patient has only a minor role to play
- But actually, it’s the other way around!
- There is lots of evidence that work done by the patient has a profound role to play
- Professional and treatment method have more of a coaching role instead of a causing role
MOST COST-EFFECTIVE EBP TREATMENT?
• Placebo!
• We must learn to use this in practice.
• Placebo is actually part of the treatment effect (it’s an integral part of the treatment effect)!
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ANTI-PSYCHOTICS
• Clear increase in placebo over decades (placebo is increasing over the years, and medication effect is decreasing).
• Same for anti-depressants.
• If you provide psycho-social context to the trial, the medication effect drops and placebo increases.
HAWTHORNE EFFECT
• Hawthorne effect = the tendency to react according to the investigators’ expectations when patients are aware of being under
study.
- Observation changes behavior!
EXPECTATION
• Expectation is super important!

• If you compare a placebo pill with an active pill, you can create a condition in which if you label the placebo as active treatment, you
can get the same effect as if you label the active treatment as the placebo!
• You can make a treatment effective by introducing a notion of effectiveness to the treatment.
• Your expectation impacts the outcome!
HUMAN ATTENTION
• The extra follow-up session effect.

• The more intensive the context in space over time, the more effective it is.
- Two times a week is more effective than one time a week
RELATIONSHIP MAKES THE DIFFERENCE
• In treatment, relationship makes the difference.

• If there is a good relationship with the therapist, psychological therapy has a big effect, but if there is a poor relationship, it makes
them worse.
• Clinician makes the difference, also in drug outcomes!
- Analysis of NIMH!
- The % variance of getting better was higher with how it was prescribed (psychiatrist) more than what was prescribed
(anti-depressant)
TRANSTHEORETICAL RELATIONISM AND RITUAL
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• Context of trust, hope and healing (in the existential sense of helping people to integrate).
• Ritual with plausible explanatory model and theory of change (you need to be the professional).
• Relationship (ask the patient, how is our relationship?).
• Finding motivation to do the work (there is work to be done by the person, and you’re going to help the client by being there and
motivating and coaching).
RELATIONIST ‘SKILLS’
• Trust
• Disclosure
• Positive expectations
• Motivates
• Emotional expression
• Active and caring
• Empathy
• Collaborates
• Manages conflict
• You can learn these skills too!
• Be open to feedback from colleagues.
• For recovery of psychosis, belonging to a community is extremely important!
EXPERIENTIAL KNOWLEDGE: CHIME-D
• Connectedness
• Hope and optimism
• Identity
• Meaning in life
• Empowerment
• Difficulties
• ‘Turning points’ = insights after an encounter
PUBLIC MENTAL HEALTH
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• Recovery colleges – Enik Retreat (Utrecht)

• Social holding
• eCommunities
• Local communities
TRANSDOMAIN SOCIAL CARE-MEDICAL CARE: SOCIAL HOLDING
• Recovery college
• ‘Housing first’
• Community retreats
• Open dialogue
• Crises advanced directives
• Network building (J.I.M.)
• Local ‘quarter master’
MENTAL HEALTH REQUIRES: INTEGRATION
• Of science and psychiatric tradition.

• Of professional and experiential knowledge.
• Of health and social care.
• Of EBM and relational care.
- Much more about clinical reasoning
• Focus on “What has happened to you?” instead of “What’s your problem?”
• What are your strengths and vulnerabilities?
• Where do you want to go in your life? What is your life’s purpose?
• So, what would you need in order to achieve your goals, given your current circumstances?
- Society of Psychotherapy Research (SPR)?
THEME 4
LITERATURE
SLADE – CHAPTER 15: THE FOUNDATIONS OF A RECOVERY-FOCUSED MENTAL HEALTH SERVICE
Working in a recovery-focused way starts with a consideration of values.
VALUES
Any intervention has embedded values and creates ethical dilemmas. To make a change requires three processes:
1. Making values explicit
2. Embedding values in daily practice
3. Tailoring practice using performance feedback
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1. MAKING VALUES EXPLICIT
People with severe mental illnesses are people, and mental health services have to support progress towards goals such as to work,
love, play, make choice, be citizens – all the normal entitlements, roles and responsibilities of being a person.
THE FOUR CRITICAL RECOVERY VALUES OF THE CENTER FOR PSYCHIATRIC REHABILITATION
1. Person oriented
2. Person involvement
3. Self-determination/choice
4. Growth potential
RECOVERY VALUES AT THE MHA VILLAGE
1. Client choice
2. Quality of life
3. Community focus
4. Whatever it takes
TEN RECOVERY PRINCIPLES OF THE YALE PROGRAM FOR RECOVERY AND COMMUNITY HEALTH
1. Care is recovery-oriented
2. Care is strength-based
3. Care is community-focused
4. Care is person-centered
5. Care allows for reciprocity in relationships
6. Care is culturally responsive
7. Care is grounded in the person’s life context
8. Care is relationally mediated
9. Care optimizes natural supports
10. It (really) is your job
PROPOSED VALUES FOR A RECOVERY-FOCUSED MENTAL HEALTH SERVICE BY SLADE
1. The primary goal of mental health services is to support personal recovery.

2. Actions by mental health professionals will primarily focus on identifying, elaborating and supporting work towards the
person’s goals.
3. Mental health services work as if people are, or (when in crisis) will be, responsible for their own lives (you can do it
and we can help)
These values point to the need for a new balance, with less responsibility for and more responsibility with the person.
2. EMBEDDING VALUES IN DAILY PRACTICE
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• Involves both bottom-up and top-down ownership, and requires skilled leadership and system transformation.
3. TAILORING PRACTICE THROUGH PERFORMANCE FEEDBACK
• Without good information about success, the natural tendency is to assume all is well.
• Stop – start – continue approach = using evaluation data to identify what needs to stop, to start or to continue to amplify the
presence of the intended values in the organization.
• Clinical reality can make it difficult to follow values.
EVIDENCE-BASED PRACTICE AS A CONTRIBUTOR TO RECOVERY
• Treatments are effective, for some people, some of the time.

• The central limitation of EBP is the tendency to reduce rather than amplify meaning.
• The more central EBP becomes, the more decontextualized, objectified and divested of meaning the patient becomes.
• So, whilst EBP has an important contribution, in a recovery-focused service it is a tool rather than a clinical imperative.
NARRATIVE-BASED PRACTICE AS A CONTRIBUTOR TO RECOVERY
• The aim of listening is to understand what the patient is saying.

• Narrative-based medicine highlights the role of literature in giving insights into the human condition, and can act as a balance
to the reductionism of evidence-based medicine.
• Understanding is a matter of narrative, and the application of scientific treatments needs to be consistent with the patient’s narrative.
This integration provides a vehicle for placing the patient’s meaning center-stage.
VALUES-BASED PRACTICE AS A CONTRIBUTOR TO RECOVERY
• Ten pointers to good process in values-based practice:

1. The two feet principle = all decisions are based on values and facts, including decisions about diagnosis.
2. The squeaky wheel principle = we tend to notice values only when they are diverse or conflicting and likely to be
problematic.
3. The science driven principle = increasing scientific knowledge creates choices, which brings the full diversity of human
values into play.
4. The patient-perspective principle = the first source of values information is the perspective of the patient.
5. The multi-perspective principle = conflicts of values are resolved by balancing legitimately different perspectives, not
by reference to a predefined rule.
6. The values-blindness principle = careful attention to language use raises awareness of values
7. The values-myopia principle = first-hand narratives, survey, media and social science reports can all improve our
knowledge of other people’s values.
8. The space of values principle = ethical reasoning is employed to explore differences of values, not to determine ‘what
is right’.
9. The how it’s done principle = communication skills are central to conflict resolution and clinical decision-making.
10. The who decides principle = decisions are taken by patients and professionals in partnership.
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• A mental health service using a values-based practice approach necessarily places great emphasis on the dreams, aspirations
and goals of the person. This approach therefore promotes a focus on personal recovery.
REHABILITATION AS A CONTRIBUTOR TO RECOVERY
• Rehabilitation services work longer-term with people who have severe and enduring mental illness. There is a difference between
rehabilitation and recovery:
- Rehabilitation = the services and technologies that are made available to disabled persons so that they may learn to
adapt to their world
- Recovery = the lived or real-life experience of persons as they accept and overcome the challenge of the disability
• Rehabilitation services are concerned with bridging the gap between an individual and their aspirations, through effective
treatments, skills training and practical and emotional support. These are key pro-recovery skills, which perhaps accounts for the
close alignment between rehabilitation and recovery.
• A key challenge to mental health practitioners will be to provide best possible recovery-oriented rehabilitation services, whilst
simultaneously recognizing that, for some people, their journey to recovery is primarily or exclusively outside mental health
services.
DIFFERENCES BETWEEN TRADITIONAL AND RECOVERY-FOCUSED SERVICES
Traditional approach Recovery approach

Values and power arrangements
(Apparently) value-free Value-centered
Professional accountability Personal responsibility
Control-oriented Oriented to choice
Power over people Awakens people’s power
Basic concepts
Scientific Humanistic
Pathography Biography
Psychopathology Distressing experience
Diagnosis Personal meaning
Treatment Growth and discovery
Doctors and patients Experts by training and experts by experience
Knowledge base
Randomized controlled trials Guiding narratives
Systematic reviews Modelled on heroes
Decontextualized Within a social context
Working practices
Recognition Understanding
Focus on the disorder Focus on the person
Illness-based Strengths-based
Based on reducing adverse events Based on hopes and dreams
Individual adapts to the program Provider adapts to the individual
Rewards passivity and compliance Fosters empowerment
Expert case co-ordinates Self-management
Goals of the service
Anti-disease Pro-health
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Bringing under control Self-control

Compliance Choice
Return to normal Transformation
SLADE – CHAPTER 16: ASSESSMENT
The aims of the assessment in a recovery approach differ from the traditional clinical goal of identifying the illness and planning the
treatment.
AIMS OF A RECOVERY-FOCUSSED ASSESSMENT
1. To promote and validate the development of personal meaning

2. To amplify strengths rather than deficits
3. To foster personal responsibility rather than passive compliance
4. To support the development of a positive identity rather than an illness identity
5. To develop hopefulness rather than hopelessness
USING ASSESSMENT TO DEVELOP AND VALIDATE PERSONAL MEANING
There is a distinction between the person experiencing the mental illness and the mental illness itself!
FOUR NEEDS FOR MEANING
Type of meaning Definition Implication for working practices in mental

health services
1. Purpose Present events draw meaning from their Listen for personal meaning and meaning-making
connection with future events approaches in accounts of past and current events
Two types:
a. Goals An objective outcome, such as job promotion, Identify personal goals, provide goal-setting and
having a child, etc. goal-striving support, facilitate access to mainstream
opportunities (employment, education, leisure,
social)
b. Fulfilments A subjective anticipated state of future Encourage optimism and hopefulness, ask future-
fulfilment, such as being in love, going to oriented questions – “Where would you like to be in 5
Heaven years?”, “How can I support you to work towards that
dream?”
2. Values Lends a sense of goodness or positivity to life, Support spiritual development by facilitating access
can justify certain courses of action to religious, faith, humanist, cultural or political
groups, avoid undermining the individual’s values by
imposing personal or professional values (e.g., a
clinical model, the importance of empiricism, societal
norms)
3. Efficacy A belief one can make a difference Identify and amplify times of well-being, when
person showed mastery and coped with
unanticipated difficulties, plan ahead, identify
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personal and social resources, support the

development of crisis plans
4. Self-worth Reasons for believing one is a good, worthy Actively encourage the person to take on ‘giving back’
person roles – voluntary work, co-running a group, writing
about their experiences, becoming a peer mentor,
foster affiliation with high-status groups (especially
outside the mental health system)
THE FIVE CULTURAL TENETS OF THE YALE PROGRAM FOR RECOVERY AND COMMUNITY HEALTH
1. Working with clients is inevitably a cross-cultural enterprise

2. Becoming culturally competent is a process not an end point
3. A central part of working effectively across cultures is becoming aware of our personal cultural filters
4. Group-specific information can be used as a starting point for exploring individual experiences
5. Stereotyping is a natural part of the human perception process, but is one we need to be aware of and challenge
• For the patient, integration of the direct meaning of the mental illness into personal and social identity is a key step on the
journey of recovery.
• It is also a very personal process – it cannot be done to the person, so assessment involves working with the person to help them
develop their own explanation.
• A desire for many patients will be to reduce anxiety by wanting an answer from the expert. Therefore, part of the assessment will
involve collecting enough information to be able to offer a clinical perspective, and to develop treatment goals.
• There should be no withholding of a view about diagnosis, but there should also be a tentativeness in how it is used in the
assessment process. It is a resource to offer to the patient, not ‘the’ answer. It is not an explanation, but a description.
• The basic orientation of the assessment process is towards helping the patient and the clinician to understand the experience,
rather than to explain the cause.
THREE APPROACHES IN RELATION TO EXPERIENCES OF PSYCHOSIS
1. Finding specific and concrete meaning – listening without filtering through a clinical model, to understand the developmental
and autobiographical context in which experiences take place.
- Has this in some sense actually happened to the person? – a delusional belief won’t have literally happened, but may
have happened in a different context or time
2. Understand metaphoric or thematic associations – following the feeling, or emergent themes, in the way the person talks
about their experiences and viewing delusions as unlabeled metaphors.
- This normalizes the experiences – you don’t have to have a mental illness to have unresolved issues – and provides an
opportunity to support the person in developing self-awareness and new identity formation
3. Understanding the purpose and significance of an individual’s elaboration of their psychosis – setting aside entirely the issue of
where the experiences have come from, and focusing instead on what maintains and reinforces the person’s interpretation.
- Is this a helpful way for the individual to make sense of their experiences? ® leads to a hope-promoting focus on making
the future better, rather than a hope-destroying account of the individual as incomprehensible
• Three levels of understanding are thus being differentiated:

1. Understanding the meaning of madness – how does it arise?
2. Understanding meaning in madness – either specific or metaphorical
3. Understanding meaning through madness – existential considerations
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• The outcome of the individual’s quest for meaning may or may not be consistent with a clinical perspective. A recovery value is that
it doesn’t matter. It is not the job of mental health services to make people rational or normal, but “to embrace our human vocation
of becoming more deeply, more fully human”.
• Understanding the person’s behavior as an effort to cope with their experiences rather than as a symptom of mental illness can
be helpful.
• Cognitive Appraisal Model = coping is constantly changing cognitive and behavioral efforts to manage specific external and/or
internal demands that are appraised as taxing or exceeding the resources of the person.
- Coping strategies are cognitive and behavioral responses intended to reduce either the gap between reality
(environmental outcomes) and wants (ideal self-image), or the threat (cognitive dissonance) associated with the gap
- Coping responses are generated by (a) appraising the situation, e.g., in terms of demands, threats, opportunities; (b)
identifying the available resources for managing the situation; and (c) estimating the consequences of different responses
- Coping responses are influenced by appraisal (e.g., controllability, relevance) and may have effects on motivation,
cognition, emotion or interpersonal functioning
• Groupings:
1. Differentiation between the focus of the coping response:
- Problem-focused coping = changing the environment
- Emotion-focused coping = intrapsychic change to reduce the mismatch or perceived threat
- Meaning-focused coping = reframing the meaning of the event or situation to make it more compatible with beliefs
and goals
2. Avoidance versus approach strategies:
- Approach strategies deal with a mismatch between self and environment by actively confronting the problem
- Avoidance strategies deny the mismatch or seek to escape the damaging consequences
Coping Thoughts Feelings Behaviors Clinical

response interpretation
Emotional Emotionally “There’s no • Drained • Drug and alcohol • Disengaged
avoidance withdraw from a problem” • Dead inside over-use • Amotivational
too-painful reality • Wrung out • Social isolation • Affective
• Heavy • Day-dreaming • Blunting
• Anxious • Excessive sleep • Passivity
• Depressed • Giving up • Lacking insight
Re-framing Try to make sense “I can make sense • Suspicious • ‘Odd’ behavior • Paranoid
of the situation in of what’s • Anxious • Increased • Delusional
a way that fits with happened without • Afraid religious activity • Reasoning bias
current beliefs changing myself” • Alone • Lacking insight
• Uncertain
• Angry
Active Try to change the “I can change the • Engaged • Challenging • Non-compliant
engagement world to fit with situation without • Angry • Manipulative
beliefs changing myself”
Integration Change beliefs, “This is how • Acceptance • Ventilation of
values and goals things are. So now • Combined feelings
to better fit reality what…? happiness and • Use of social
sadness support
USING ASSESSMENT TO AMPLIFY STRENGTHS
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• Clinical assessment should focus on four dimensions:

1. Deficiencies and undermining characteristics of the person
2. Strengths and assets of the person
3. Lacks and destructive factors in the environment
4. Resource and opportunities in the environment
• Up close, nobody is normal: a deficit-focused discourse will always elicit confirmatory evidence for an illness-saturated view of the
person.
MENTAL HEALTH ASSESSMENT
Mental health assessment Equivalent Example questions

elements from a
standard history-
taking interview
Current strengths and History of the • How are you making sense of what’s going on in your life at
resources presenting illness present?
• What keeps you going?
• How have you found the strength to get this far?
• What do you have going for you?
• Consider spirituality, social roles, cultural/political identity, self-
belief, life skills, toughness, resilience, humor, environmental
mastery, support from others, ability to take a philosophical
approach to life or to express emotion artistically
Learning from the past Precipitating events • Was there a time when it became more difficult to cope?
• Why was that, do you think?
• What would turn the situation around?
• What have these experiences taught you?
• Are there any positive ways in which you have changed or grown
as a person?
• Consider gratitude, altruism, empathy, compassion, self-
acceptance, self-efficacy, meaning
Personal goals Risk assessment • How would you like your life to be different?
• If you woke up tomorrow and the problem had gone away, how
would you know? What would you notice had changed about
yourself, and what would others notice about you?
• What are your dreams now? How have they changed?
Past coping history Past psychiatric • How have you got through the tough times in your life?
history • What supports have you found useful?
• What do you wish had happened?
Inherited resources Genetic background • Is there any history of high achieving in your family?
• Any artistic, authors, athletes or academics?
Family environment Family environment • When you were growing up, was there anyone you really
admired?
• Who was the kindest person to you?
• Who taught you the most?
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• Who did you want to be like?

• What important lessons did you learn during childhood?
Developmental history Developmental • What was life like for you when you were growing up?
history • What did you enjoy?
• What’s your best memory?
• What skills or abilities did you discover you had?
• What came easily for you?
Valued social roles Occupational history • How would you describe yourself?
• How do other people see you?
• What would someone who knew you really well and liked you
say?
• What would you like them to say?
• How are you useful or of value to others?
Social supports Relationship history • Who do you lean on in times of trouble?
• Who leans on you?
Personal gifts Forensic history, • What is special about you?
drug and alcohol • Has anyone ever paid you a compliment?
• What do you like about yourself?
• What things that you’ve done or ways that you’ve behaved make
you feel really proud of yourself?
Personal recovery Premorbid • Do you have a sense of who you were before these problems?
personality • How did you feel about that person back then?
• Do you want to go back to how you were, or become someone
new?
• What bits of yourself then would you hold on to?
• Role expectations are central, and recovery-focused clinicians hold different expectations about the primary purpose of their role.
• The Problem Focus Cycle:
• This Problem Focus Cycle has two anti-recovery features:

1. It focuses on problems, thus reinforcing an illness identity and neglecting the innate, growth-oriented capacities and
strengths of the individual.
2. By starting with a professional imposition of meaning, the remainder of the process (no matter how sensitively done and
patient-focused) is inevitably clinician-led.
• In a partnership relationship, the assumption is that the patient knows the best solution – it is after all their life. Of course,
their view may benefit from the input of clinical expertise.
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• The Appreciative Listening Cycle:
• Four steps of the appreciative listening field:

1. Discover
2. Dream
3. Design
4. Destiny
• It starts by identifying something – anything – that matters to the individual, and then working together towards that goal. The
slips along the road to meeting the person’s goal become normalized as challenges, rather than compliance issues. Setbacks
become the jumping-off point for new growth and learning, rather than treatment failures.
• The Appreciative Listening Cycle does something that the Problem Focus Cycle does not: it locates the responsibility for change
with the individual.
• The general principle across all these approaches is a stance of expecting to find more than just problems.
USING ASSESSMENT TO FOSTER PERSONAL RESPONSIBILITY
• An unintended consequence of clinicians working so hard to look after people with mental illness can be a reluctance to allow
individuals to take responsibility for their own life.
• Clinicians need to get out of the way of the person’s recovery, which means supporting the individual to take as much personal
responsibility as possible, rather than assuming responsibility for them.
• Clinicians can support this by asking questions and by facilitating, not by doing.
USING ASSESSMENT TO SUPPORT A POSITIVE IDENTITY
• One thing professionals know is that the experience of mental illness will almost certainly change the person.
• Two broad types of change:
1. Identity redefinition = redefining existing elements of identity
2. Identity growth = developing new elements of identity
Type of Identity change Examples of transformative Why this helps

meaning beliefs
Direct meaning Redefinition My mental illness means I cannot I can lead my life the rest of the time
of mental illness function some of the time, rather
than all of the time
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I have more control than anyone else Increased agency and empowerment
over my mental illness
Growth My mental illness has led me to (a) increased self-knowledge
understand myself in new ways (b) value and meaning placed on
experience
Indirect Redefinition My mental illness has happened (a) life becomes more meaningful
meaning for the because of my childhood (b) development of coherent
person personal narrative
My mental illness means I am in Increased value associated with self
touch with my creativity as a whole person, rather than self-
image as being damaged
Growth I am more compassionate to others (a) becoming a ‘better’ person is
now socially valued
(b) being compassionate with others
can lead to greater self-compassion
My mental illness has given me a (a) development of a social role
job, teaching about mental health (b) using own experiences
issues (c) benefiting others
• It can be difficult to see the person when the illness is very prominent.
1. Draw from non-mental-health approaches to amplify a positive identity.
2. Use a time-line to help put the person as they are now into the broader context of their own life.
3. Deliberately increase involvement with the person when well, so that the worker can hold a picture of the well
person during crisis.
• Assessment at the level of indirect meaning is important, in giving the person a chance to process and make sense of what the
mental illness means for them as a person.
• For the clinician, this involves giving the patient an invitation to open up the conversation.
USING ASSESSMENT TO DEVELOP HOPE
Using interpersonal resources Activating internal resources Accessing external resources

Values Valuing the person as a unique Failure is a positive sign of Target efforts towards supporting
human being engagement, and contributes to the person to maintain
self-knowledge relationships and social roles
Trust in the authenticity of what the To be human is to have Find or build an audience to the
person says limitations – the challenge is to person’s uniqueness, strengths
exceed or accept them and best efforts
Attitudes Believing in the person’s potential Losses need to be grieved for Housing, employment and
and strength education are key external
resources
Accepting the person for who they The person needs to find Employ recovered consumers in
are meaning in their mental illness, services as role models
and more importantly in their life
View set-backs and ‘relapse’ as part
of recovery
Behaviors Listening non-judgmentally Support the person to set and Facilitate contact with peer role
reach personally valued goals models and self-help groups
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Tolerate the uncertainty about the Support the person to develop Be available in crisis
person’s future better approaches to coping
Express and demonstrate a Help the person to recall Support access to a full range of
genuine concern for the person’s previous achievements and treatments and information
well-being positive experiences
Use humor appropriately Support and actively encourage Support close relationships
exploration of spirituality
• Recovery begins with hope, and is sustained by acceptance. Hope, not acceptance, is the starting point.
• In practice, this means the assessment conversation between clinician and consumer in a recovery-focused service may look
different, in two ways:
1. The topic of interest is the person not the illness, and promotion of well-being is as important as treatment of illness (therefore,
the content is not solely about deficits).
2. The discourse is not a one-way relationship, focused on the clinician assessing the patient and then providing expert advice
(rather, the discourse is as much about helping the consumer to learn about themselves as giving the clinician the information they
need).
• Two suggestion:
1. Perhaps the biggest weapon of depression is that it is a killer of hope. Addressing experiences of depression can be an
important step towards the person being able to take personal responsibility.
2. It is helpful for clinicians to talk about recovery. The very existence of the concept in clinical discourse has transformative potential,
and acts as a counterbalance to the alternative implicit message that long-term contact with mental health services is the norm.
MESSAGES TO COMMUNICATE THROUGH ASSESSMENT
• Professional-to-patient assessment messages which support recovery:

1. The experience you are going through is meaningful, and part of your journey in life. I will use all my expertise to support you to
make sense of what is happening to you, working with you to help find your own way forward. I don’t know what will happen to you,
but I do know that many people with similar experiences have recovered their life.
2. Some people with similar experiences find it helpful to make sense of what is going on as a mental illness. Others develop their
own meaning through contact with others who have been through similar experiences. Some make sense of what has happened
to them in spiritual terms, or in other ways entirely outside the mental health system.
3. Whatever sense you make of it, you will over time increasingly fit this experience into a bigger picture of who you are as a person.
Although you may change as a result, you will control the direction of the change. A point may come where you can even identify
good things that have come out of the experience.
4. It’s fine to hope for miracles, but don’t expect them! As you become ready, the challenge will be for you to make decisions about
your own life. This is going to be hard work – but you won’t be alone.
• The intention is not to be unrealistic. The clinical skill during crisis is to provide a map back to experiencing hope and personal
responsibility. The skilled recovery-focused clinician:
- Connects with the person where they are, accepting that their unusual beliefs, statements and behavior are meaningful
- Accepting involves not imposing an explanatory model, but offering alternative explanations in a tentative and
non-authoritative way
- Will offer pointers for the direction of travel, which can involve discussion about help and support which is available
now or when the person is ready, overt discussions about power, positive goal-setting, being a holder of hope for the
person when they are hopeless, or being a spring safety-net instead of a sagging safety-net by actively easing the person
back into their life
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- Will use their expertise-by-training as a resource for the client, which might involve “Other people I have worked with
have found X useful”, or “Although it’s hard right now to even think about talking about what you are going through, as
soon as you do manage to disclose even a small part you may well experience a real sense of achievement. It will probably
still hurt, but it will be the pain of healing.”
SLADE – CHAPTER 17: ACTION PLANNING
• It is important to distinguish between goals that are important to the person and goals that are important for the person.
• Recovery goals are the individual’s dreams and aspirations:
- Influenced by personality and values
- Unique, often idiosyncratic
- Forward-looking
- Harness approach motivation rather than avoidance motivation
- Strengths-based
- Oriented towards reinforcing a positive identity and developing valued social roles
- Personal responsibility
- Dreams with deadlines
• Treatment goals arise from the societal requirements and professional obligations imposed on mental health services to constrain
and control behavior and improve health:
- Set by the clinician on the basis of societal, legal and professional requirements
- Relate to serious harmful risk, symptoms, medication and lifestyle choices
- About minimizing the impact of an illness and avoiding bad things happening (such as relapse, hospitalization, harmful
risk, etc.)
- Doing-to tasks undertaken by the clinician
- Provide the basis of defensible practice
- Important and necessary
• The difference between these goals highlights the assumption that people with mental illness need treatment, whereas everyone
else needs well-being – a perspective of fundamental otherness which needs to change before a recovery focus is possible.
• This difference is unhelpful because:
- It suggests that clinical and consumer priorities are intrinsically opposed, which is not the cause
- It creates the impression that working in a recovery-focused way can be done by getting someone else to develop recovery
goals with the consumer whilst the clinician continues with traditional treatment planning, which is not the intention
• Advantages of distinguishing between recovery goals and treatment goals:
- It is honest – it doesn’t maintain a pretense that everything in a care plan is necessarily in the person’s interest
- It promotes a focus on values – more clearly identifying actions professionals have to do makes power, choices and
control issues more explicit and hence amenable to debate
- It promotes a focus on the patient’s aspirations and preferences – trying to make the recovery goals of the patient
explicitly highlights the need to support the person to identify their goals and preferred methods of goal attainment
(which places their views at the heart of action planning)
- It reduces compulsion – for the clinician, a stronger orientation towards promoting self-determination leads to a
corresponding orientation away from overruling the individual in their choices and for the service user, the more that
clinical effort is directed towards recovery goals, the less the person offers resistance
- It promotes partnership – identifying treatment goals as ‘the beast to feed’ (i.e., externalizing this imperative as
something to which both parties are subject and which requires certain actions, irrespective of personal opinions)
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positions doing-to tasks as a joint problem – allowing clinicians and patients to work towards a joint goal and reducing
monitoring and compulsion
• A range of simple questions can be used:
- Ask the person what they want from life, and validate their response
- Ask the person about their dreams when they were younger – what did they used to want before the mental illness? Do
they still want it, or have they changed towards other goals?
- Ask what life would be like without the mental illness: “If you could wave a magic wand and wake up tomorrow without
this illness, how would you know it has gone? What would be different? What could you do tomorrow that you can’t do
today?”
• Systematic approaches to support the identification of recovery goals:
- Working to recovery (work-book): provides a personal planning tool for recovery
- Pathways to recovery (work-book): supports the journey of exploration, self-discovery and planning
- Wellness Recovery Action Planning (WRAP): focus on self-managing mental illness (with wellness as starting point)
PERSON-CENTERED PLANNING
• Person-centered planning starts by the person identifying goals which promote their recovery, self-determination and
community integration. This involves the person connect with their own dreams.
• The focus is on identifying goals which promote well-being and thriving, rather than avoiding illness problems and getting by.
Identified goals are often big, and always meaningful.
• Goals are never about receiving treatment as a goal in itself, but will often involve treatment as a component of progressing towards
personally valued goals.
• Objectives or stepping-stone actions are then set for each goal. Every objective is linked to specific goals – everything for a
purpose. Objectives have deadlines, to create a sense of momentum and an expectation of progress. They should be achievable
and, as far as possible, enjoyable. They are positive: “The person will …” rather than “The person will not …”. Person-first language
(“person with depression” rather than “depressive”) emphasizes the personhood rather than the illness identity. Objectives harness
strengths.
• In developing objectives, the orientation is towards actions the person can do for themselves, or can achieve by harnessing
existing or new natural supports in their life. Only when personal resources and natural supports are insufficient is consideration
given to a service response – because it is better to get the support from the system than not at all.
• Structural approaches can help to support person-centered planning. For example, having three parts to the intervention section of
each plan: actions to be done by the consumer, ways in which the person’s natural supports will contribute, and actions the mental
health service will take.
• The paradox at the heart of this book is that when the person finds effective ways to get on with their life, there is less need for
treatment. Providing effective treatment is therefore not the best starting point. Life is about recovery goals, not treatment goals.
SLADE – CHAPTER 18: SUPPORTING THE DEVELOPMENT OF SELF-MANAGEMENT SKILLS
THE OFFERING OF TREATMENT
• Providing treatment is not the primary purpose of mental health services.

• A recovery-focused service supports people to use medication, other treatments and services as a resource in their own recovery.
• This means that EBTs are (with two exceptions) offered, not imposed.
• The challenge is to work with (not on) the person: services on tap, not on top.
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• The secondary functions of treatment are to meet treatment goals and to deal with crises. These are the two exceptions to the
principle of offering rather than imposing treatments. Meeting these functions may involve compulsion – things being done to the
consumer in a non-negotiated way. Treatment goals will typically relate to issues of risk and safety.
• Mental health services should as much as possible be focused on recovery goals. The aim of treatment is to foster the development
of self-management skills, not to fix the problem.
SUPPORTING SELF-MANAGEMENT
• Self-management involves the systematic provision of education and supportive interventions by health care staff to increase
patients’ skills and confidence in managing their health problems, including regular assessment of progress and problems, goal
setting, and problem-solving support.
• A consumer definition would also emphasize the importance of empowerment, hope, exposure to role models, and working
towards personally valued recovery goals.
• Two implications:
1. It provides an insight into why some people might be reluctant to give up the role of patient – taking responsibility for
one’s own life can be scary.
2. It shows that (just like recovery itself) responsibility is something that is taken by the person, not given to the person.
• Many recovery-focused services pay particular attention to how people are welcomed. Displaying stories of recovery rather than
medication information in the waiting room creates different expectations. Providing fresh fruits and drinks costs little, and
communicates a message of respect. The first personal contact is also important. The Living Room service uses a peer-led triage
service, so the first contact of someone in crisis is with a peer rather than a professional worker.
SUPPORTING THE DEVELOPMENT OF AGENCY
• A necessary requirement for self-management is a sense of agency: a self-belief that the person can impact on their own life.
• Developing a sense of agency can be a painful process for the consumer, often starting with accepting that they have an illness or
in other ways finding a direct meaning that fits. This acceptance can involve changes to how the person thinks about and
understands challenges in life. Because it can be a painful process, consumers may take time to come to the point of doing that
work.
• One way of avoiding responses that get in the way of recovery is through self-awareness by the clinician. Clinicians can do many
things to increase agency:
- Foster hope
- Identify strengths and dreams
- Support goal-striving
- Set the person up to experience achievement
- Encourage them to give back to others
- Create opportunities to access mutual self-help groups
- Employ peer support workers
- Give voice to role models of success
- Support access to experiences of pleasure
- Amplify personal success
- Aid the integration of positive experiences into personal identity
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SUPPORTING THE DEVELOPMENT OF EMPOWERMENT
• Empowerment behaviors emerge from agency beliefs.

• Empowerment is behavior which impacts one’s life, whether or not this is at the level of personal identity or other levels, such
as spiritual empowerment or social identity.
• Structural approaches to increase empowerment:
- Getting the complaints procedure in place and working
- Having the option to change clinician
- Having advance directives in place and routinely used
- Offering easily accessible WRAP training
- Supporting access to self-management resources
• Strategies to promote empowerment:
- Ensuring full participation in formulation care plans and crisis plans
- Providing access to cognitive behavioral therapy to address negative self-stigma
- Creating user-led and user-run services
- Developing peer support worker roles in mental health services
- Advocating for employers to give positive credit for experience of mental illness
- Supporting user-led evaluation of treatments and services
• Assertiveness is necessary.
• Clinicians can support assertiveness by teaching the DESC script:
- Describe the problem
- Explain how it makes you feel
- Provide a solution
- State the consequence of the solution
• How staff can practice fostering rather than impeding empowerment:
- Allocate a recovery hat to an individual in each clinical team meeting: that person’s role is then to be an advocate for
patients being discussed, with input focused on how services are supporting the individual’s recovery
COPE sub-scale Behavior

1. Active coping Taking action or exerting efforts to remove or circumvent the stressor
2. Planning Thinking about how to confront the stressor, planning one’s active coping efforts
3. Seeking instrumental social Seeking assistance, information or advice about what to do
support
4. Seeking emotional social Getting sympathy or emotional support from someone
support
5. Suppression of competing Suppressing attention to other activities to concentrate on dealing with the stressor
activities
6. Religion Increased engagement in religious activities
7. Positive reinterpretation and Making the best of the situation by growing from it or viewing it more favorably
growth
8. Restraint coping Coping passively by holding back one’s coping attempts until they can be of use
9. Resignation or acceptance Accepting the fact that the stressful event has occurred and is real
10. Focus on and venting of Awareness of one’s emotional distress, a tendency to ventilate those feelings
emotions
11. Denial An attempt to reject the reality of the stressful event
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12. Mental disengagement Disengagement from the interfered with goal, e.g., daydreaming, sleep, self-
distraction
13. Behavioral disengagement Giving up, or withdrawing effort from, efforts to attain the interfered-with goal
14. Alcohol/drug use Using alcohol and other drugs as a way of disengaging from the stressor
15. Humor Making jokes about the stressor
• In a recovery-focused service, there is an orientation towards viewing resistance to change as reasonable, understandable and
normal. This leads to a helpful response to people who seem to refuse to take responsibility for themselves, and carry on with
apparently damaging behaviors.
• The WIIFM Principle motivates the behavior of most people – What’s In It For Me? The challenge is to identify what personally valued
recovery goal is being undermined by the behavior. If this proves impossible, then the behavior may be entirely rational and have
nothing to do with illness.
SUPPORTING THE DEVELOPMENT OF MOTIVATION
• The approach of motivational interviewing addresses how to initiate movement towards recovery goals.
• Motivational interviewing is a person-centered approach to supporting changes in behavior through the exploration and
resolution of ambivalence, and is oriented towards collaboration, evocation and autonomy.
• It is based on the trans-theoretical model of change, which distinguishes between precontemplative, contemplative, action
and maintenance phases of change.
• Treating a person who is not ready to change as if they are, has two toxic consequences:
1. It means the action is clinician-centered rather than person-centered, and may not be the type of action the person
themselves will ultimately find beneficial.
2. It means that the mental health service and the person are pulling in opposite directions, with the service focusing on
compliance, and the patient disengaging, becoming resentful or angry or giving up and exhibiting passivity and
dependence.
• Motivational interviewing offers a more person-centered approach, using techniques for eliciting and amplifying motivation to
change, such as:
- Ensure person-centeredness by using reflective listening to test the hypothesis about what is heard against what is
meant (“It sounds like you …”, “You’re feeling …”, “So you …”)
- Focus on why the person might want to change, now how they will change
- Focus on pro-change motivations: “Think of your recovery goal. Rate readiness to change behavior towards the goal
on a scale from 1 (not ready) to 10 (fully ready). Why wasn’t your rating lower?”
- Undershooting (e.g., “So, your cutting doesn’t cause any problems at all for you?”)
- Overshooting (e.g., “So, it seems like there’s no chance whatsoever you’ll be able to meet your goal?”)
- Questioning to increase motivation (“What makes you think you can do it?”, “If you succeed, how will things be different?”,
“What were you like before the problem emerged?”, “What worries you about this situation?”, “What’s the worst that
could happen if you don’t make a change?”)
- Explore values (“What are the most important things in your life?” Note behavior-value contradictions!)
SLADE – CHAPTER 19: THE CONTRIBUTION OF MEDICATION TO RECOVERY
MEDICATION AND CHOICE
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• In a recovery-focused mental health service, a full range of psychotropic medication is available. However, the job of the service is
not to get medication taken, whatever the cost. The job, of course, is to support personal recovery.
• David Whitwell suggests the following causes for non-adherence to medication:
- Loss of autonomy
- Accepting something of which they disapprove
- Taking tablets to deal with mental suffering is seen as weak, stupid and superficial
- Viewing it as being prescribed to shut them up
- Link with coercion
- Direct side-effects, toxic effects, stigma, and uncertainty about effectiveness
• Overall, automatically assuming that a decision not to take medication as prescribed is irrational, unhealthy, indicative of impaired
insight and not in the person’s best interest is a belief that gets in the way of supporting recovery.
• For psychiatrist and other prescribers, an embedded current value is that the job is to prescribe – failing to prescribe would be
negligent. This value creates the context in which a person who decides not to take their medication is labelled as lacking insight
and non-compliant. Passive compliance is antithetical to personal responsibility!
• All approaches to trying to make people take their medication get in the way of personal recovery; they disempower the patient,
they take away responsibility from the individual for their own well-being and they promote passivity and dependence.
• The job of the clinician is to give genuine choice and control about medication to the service user. The content of the individual’s
decision about medication is in a sense irrelevant – what matters is the extent to which the person is taking responsibility for their
well-being.
MEDICATION AND RECOVERY
• The change in a recovery-focused service is that the psychopharmacological expertise is meshed with the consumer’s expertise about
their own values, beliefs, goals and preferred approaches to meeting challenges. Even if medication always impacted beneficially
on symptoms (which it does not), individuals vary widely in the importance they attach to symptom reduction.
• Medication may or may not be necessary for recovery – the journey of recovery involves finding out whether it has a part to
play. The discussion needs to focus on what will be helpful for the individual, and in order to have that discussion the first thing
that needs clarifying is the person’s recovery goals.
• Decision-support approaches:
- Reframe medicine as much more than solely pharmacological – all the things that people do to feel better: laughter,
love, hope, caffeine, exercise, chocolate, etc. in other words, medicine is what you do, not just what you take
Ø Pill medicine is than a sub-set of personal medicine
Ø Finding the balance between pill medicine and other forms of personal medicine is central
- Orientation towards supporting the person to take responsibility for their own lives
- People will be supported to come off medication
• A recovery-promoting approach is thus to view medication as an ‘exchangeable protection against relapse’, in which
pharmacological and psychosocial approaches both buffer the individual against relapse.
• Framing medication as a potential tool for sustaining well-being creates a very different dialogue. The advantage of this view is that
it creates a focus on promoting resilience (which definitely matters) rather than on medication (which may or may not matter).
- Resilience can be supported by working with the consumer to identify answers to the statements “I have …” (external
supports of people and resources), “I am …” (inner personal strengths) and “I can …” (social and interpersonal skills)
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DE JONG ET AL. – HOW DANGEROUSNESS EVOLVES AFTER COURT-ORDERED COMPULSORY

PSYCHIATRIC ADMISSION: EXPLORATIVE PROSPECTIVE OBSERVATIONAL COHORT STUDY
• Although compulsory admissions are commonly seen as necessary and justified for patients whose psychiatric condition is a
severe danger to themselves and others, they also represent a serious breach of personal autonomy.
• The core criterion for compulsory emergency admissions in the USA and many European countries is mental illness resulting in
danger to self or others. While certain countries apply two criteria – both need for treatment and dangerousness – three European
states apply one criterion for compulsory admission: the need for treatment caused by a mental illness.
• To date, it is an open question in general psychiatry whether and to what extent compulsory admission contributes to reducing
dangerousness to self and others. Neither is it known whether subgroups of patients can be identified whose levels of
dangerousness to themselves and others are persistently high despite compulsory admission. Conceivably, dangerousness is
greater and more persistent in patients whose symptoms are more severe at the start of compulsory admission, whose illness insight
is poorer, and whose treatment engagement is poor.
• As care may be improved by identifying these subgroups of patients and then devoting extra attention to them, we wished to study
the development of dangerousness to self and others over a 12-month period in adult psychiatric patients who had been admitted
compulsorily to a general psychiatric hospital. We also wished to identify any associations between the development of
dangerousness and these patients’ baseline demographic and clinical characteristics.
METHOD
• As a tool to assess severity of dangerousness to self and others in general psychiatric patients, we developed a Dangerousness
Inventory (DI).
• Danger to self was assessed on the basis of four items derived from the legal text in the Dutch BOPZ act: the risk that
- The individual will die by suicide or inflict severe self-harm
- The individual will fail to cope in society
- The individual will seriously neglect himself or herself
- Through his or her behavior, the individual will elicit the aggression of others
• Danger to others was also assessed on the basis of four items derived from the legal text: the risk that
- The individual will commit murder or seriously harm others
- The individual will be a burden on the mental health of others
- The individual will neglect those for whose care he or she is responsible
- The individual will endanger the overall safety of people and goods
RESULTS
• Inability to cope in society was by far the most common dangerousness criterion.
At baseline, 86.2% of the participants showed dangerousness. The proportion of scores ≥3 for any item of danger to self was
76.4% and to others was 46.6%.
• At 6-month follow-up, these proportions had fallen to 36.2% (all items), 32.8% (danger to self) and 17.2% (danger to others).
• At 12-month follow-up, the proportions were again slightly smaller.
• Whereas dangerousness disappeared from a majority of the participants within 6 months of admission, it persisted in a substantial
minority (28.7%) even after 12 months.
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PREDICTIVE FACTORS ASSOCIATED WITH THE EVOLUTION OF DANGEROUSNESS
• In the danger to self-subgroup, the persistence of danger to self at 6-month follow-up was associated with:
- Age
- Being homeless (only significant predictor in multivariate analysis)
- Previous compulsory admission
- High dangerousness at baseline
• In the danger to others-subgroup, persistence of danger to others at 6-month follow-up was associated with:
- Ethnicity
- Being homeless (only significant predictor in multivariate analysis)
DISCUSSION
• At baseline, the most common dangerousness criterion was inability to cope in society.
• During the 12-month observation period, levels of dangerousness decreased considerably in the majority of the participants. In our
view, this is a meaningful and clinically relevant observation. However, it is also important to note that dangerousness persisted in
a substantial minority of patients.
• In both the danger to self and danger to others subgroups, persistent dangerousness at 6-month follow-up was associated with
homelessness at baseline.
BOEVINK – FROM BEING A DISORDER TO DEALING WITH LIFE: AN EXPERIENTIAL EXPLORATION OF THE
ASSOCIATION BETWEEN TRAUMA AND PSYCHOSIS
• The main point of the article (story) is that individuals with psychosis are dealt with as the disorder itself and that there is not enough
attention for the association between childhood trauma and psychotic experiences.
• Several points that I found interesting:
• A psychosis is far-reaching and overwhelming. A psychosis involves a severe distortion of meaning. It renders the world
unfamiliar, unrecognizable, a threat. Psychosis can turn life into a living hell. Just ‘being’ can no longer be taken for granted.
Nothing can be taken for granted. A psychosis is also accompanied by a sense of estrangement. What you have is often closely
allied to who you are. The manifestations sometimes dominate your entire personality. The distinction between the individual
and the condition is soon lost, and it is very difficult to regain.
• Interventions are mostly aimed at the biological factors, and the psychosocial context is often ignored. We (individuals with
psychosis) are examined but not really seen; we are listened to but not really heard.
• The only thing I tried was to stay away from my dark side as far as possible. This was encouraged by the professionals I met in the
course of my life. So, I covered it up, this disorder inside myself.
• To accept my psychotic experiences as a disorder felt like surrendering, not in the least because of the nasty side effects of the
antipsychotics. I couldn’t see how to combine this with all that I had achieved so far. So, I wanted to learn to talk about my
psychotic experiences, to communicate about them, and to learn to see their meaning.
• My psychoses are my way of reacting to my life history. They are my response to the unpredictable abuse I had to face as a child.
• I don’t think that abuse itself is a strong cause for psychosis. It hurts, but it is rather simple. I think that the threat and the betrayal
that come with it feed psychosis. The betrayal of the family that says, “you must have asked for it,” instead of standing up for you.
That is a distortion of reality that is very hard to deal with when you’re a child. You are forced to betray yourself. That is what
causes the twilight zone. What makes you vulnerable for psychosis.
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• In psychiatry my twilight zone was extended. There a distortion of reality was forced on me once more. Nobody ever asked me what
had happened to me. Nobody ever asked me, “What was it that drove you mad?” I was observed, diagnosed, and treated as a
disturbed person, but nobody ever looked at the association with my life history. Many victims of abuse entertain huge guilt
complexes, and we are convinced we are to blame for the crime of which we, in fact, are the victim.
• In becoming a psychiatric patient, we are supported in our belief that we are bad. As psychiatric patients we in fact keep alive
the patterns with which we are so familiar. Becoming a psychiatric patient could essentially be called a repetition of trauma.
• My psychotic experiences are no longer a mystery. I know what triggers them and what makes my memories turn into
uncontrollable flashbacks and incomprehensible hallucinations. I learn to describe them. That makes them less threatening. I
have discovered that certain hallucinations are not threatening in themselves. It is the fact that I see something which I know
shouldn’t be there that scares me most.
• I have also discovered a sequence in the development of my psychoses. I have to work hard to avoid flashbacks and memories,
so there is always stress and exhaustion. Next, there is chaos in movement. Then there is a distortion of meaning. The world
is no longer recognizable for me; there is something fundamentally wrong in the world. That frightens me and leaves me without
boundaries. Then I start seeing things that others don’t see, and to make that right I build my own logical system of thought.
Once I am this far, it is hard to go back, because every response of others is integrated in my delusion.
• In the stage of distortion of meaning and fear, I now try to communicate with others. I learn to recognize my early signs. But this
is no guarantee or prevention of a psychosis. Self-management is only possible to a certain extent. A psychosis remains
treacherous.
• For me, it is effective to discover the association between psychosis and life history. It diminishes my self-distrust because it
makes my psychotic experiences understandable.
• When I was overwhelmed with my psychosis and my life history, I wasn’t aware of this association. I only saw isolated parts. That is
why someone else, a professional caregiver perhaps, should make the association visible.
• I wanted to illustrate that psychosis could be an understandable response to trauma, a more likely response than is acknowledged
now. There is evidence that traumatic experiences like child abuse are associated with psychotic experiences.
MULTIDISCIPLINARY MENTAL HEALTH CARE RESEARCH
UNIDIMENSIONAL ONTOLOGY
• Ontology = theory of being, our worldview, how the world is organized, what is truth.
- The type of glasses you put on to look at the world
• Epistemology = theory of knowledge, how we as human beings can understand the world, the way we can obtain knowledge
about the world.
THE MEDICAL MODEL OF PSYCHIATRY
• Ontological premise = one universal (predominantly physical) world that behaves regularly (mental health issues are
understood from a disease model).
• Epistemic premise = that we can explain mental disorders in a systematic way.
• Research: observe symptoms systematically, develop treatment protocols, infer causal impact of treatment protocols on presence
disorder
• Treatment: protocolled treatment, dose-response, stepped care
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• This is all part of the symptom-reduction model (Van Os et al., 2019).

• This is the core of evidence-based treatment (EBT).
• This all guides the way we do research!
EVIDENCE IN PSYCHOTHERAPY RESEARCH
• Evidence-based treatment: methodological procedure as warrant for evidence.

- We all have to follow a methodological procedure, and as long as we use this, we can trust that the results are indeed
the type of evidence that helps us to trust the treatments we give to people
• Evidence hierarchies:
1. Meta-analysis (putting RCTs together to see whether over the course of a number of RCTs the evidence still holds and how
strong that is)
2. RCT
3. Cohort study
4. Case-control study
5. Case reports
6. Opinion/research agenda
THE GOLD STANDARD
• RCT = systematic comparison of group level symptom development pre-post treatment.

- Wait-list isn’t ethical anymore, so now we compare it to another EBT
- Look into change over time
• Methodological requirements:
- Comparable populations ® homogeneous samples
- Well-defined outcome variable (dependent variable) ® eligibility criteria: presence of a target symptomatology, no
comorbidity
- Systematic and well-defined intervention (independent variable) ® protocolled treatment
- Keep all possible interfering factors as even over samples as possible ® random allocation to interventions
- Keep expectancy effects limited ® placebo control, but in reality, often comparative trials with TAU or another EBT
METHODOLOGY SHAPES FINDINGS
• Assumption of malleability (to be changed or formed):

- “The longer the therapy, the more variability, the less one can draw causal conclusions. As we argue, the preference
for brief treatments is a natural consequence of efforts to standardize treatments to bring them under experimental
control.” (Westen et al., 2004, p. 633)
- Leads to the assumption that short is always better in clinical practice! Which is not backed up by research at all. The
treatments are short because of keeping the confounding factors as little as possible.
• Paradox of pure samples:
- “Interventions to address such [polysymptomatic/comorbid conditions] will, as simple result of methodological
preconditions, never be identified if investigators routinely start with less complex cases and focus studies in the
community on interventions previously validated in RCTs.” (Westen et al., 2004, p. 637)
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- Homogeneous samples fit the methodological model better, but that doesn’t say that treatments don’t work for people
with comorbidity, we just haven’t studied that because the methodology doesn’t allow it
• Paradox of manualization:
- Precondition within the RCT model
- When we manualize our treatment, the evidence we obtain is for manualized treatments
- Non-manualized treatments (more eclectic, or can change according to context) are simply not researchable because it
cannot be compared systematically
- This leads to the assumption that treatments are better when manualized, but we cannot conclude that because we
haven’t compared manualized vs non-manualized treatments!
- Basic philosophy of science = based on the natural science
- There is quite a difference between the philosophy of natural science and social sciences
ONTOLOGY & EPISTEMOLOGY: ERKLAREN
• The discourse of Erklären – Explanation:

- Ontology = there is a real, universal, regular (lawlike), outside world
- Epistemology = … that we can explain by deducing universal patterns of phenomena
- Goal: explain phenomena causally
- Method: experimental, deductive, top-down, measurement and calculation
THE MEASURABLE HUMAN BEING
• Measurement as prerequisite for gold standard.

• Systematic assessment of group level symptom development pre-post treatment.
- Systematic assessment = use of standardized symptom-focused measures (self-report)
- Symptom development = standardized measurement of target symptoms pre- and post-treatment
- Pre-to-post treatment = before the start and directly after treatment (ideally: follow-up)
- Group level: aggregated date over sample of people
• ‘The data’ will tell the story of treatment efficacy.
• Measurement in psychology: self-report questionnaires.
• Efficacy =
1. Sum scores on questionnaires per individual
2. Aggregation of pre- and post-scores over the sample
3. Aggregated difference scores per condition
4. Between-group difference (significance test)
• This set-up is very much based on the group-level symptom-reduction model.
- Very strongly criticized
- Clinically not very helpful
- Snapshot research
ALTERNATIVES FOR ‘SNAPSHOT’ RESEARCH
1. Beyond singular/linear outcome variables (beyond unidimensional research)

- Domain based ® e.g., Research Domain Criteria
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- Complex Dynamic Systems ® e.g., network theory in diagnostics

2. Beyond gold standard research design
- Efficiency vs efficacy designs (less strict inclusion, more process focus, multiple variables)
- Process research ® e.g., Routine Outcome Measurement (Boswell et al., 2013)
- Clinically significant change ® Reliable Change Index (Jacobson & Truax, 1991)
- Personalized measurement (Elliott et al., 2016)
3. Beyond measurement: “numbers are words too” (Truijens, 2016)
- Mixed methodology approach
- Qualitative stance (Hesse-Biber, 2010)
RESEARCH DOMAIN CRITERIA
• Dimensional, multi-level, developmental model of mental health development.
• RDoC are also critiqued because in practice the emphasis is pretty much on the lower two domains (neurological/biological systems)
and the more on top are often seen as triggers or mediating factors instead of the core business.
• Nonetheless it is a strong and forceful answer against the unidimensional approach.
• RDoC forces multidisciplinary research!
MULTIDISCPLINARY RESEARCH
• Interdisciplinary research = not just a psychiatric framework, but a collaboration between social work, sociologists,
anthropologists, neurologists, policy makers …
• “No practice of inquiry is ruled out a priori; multiple goals of inquiry are rendered plausible and multiple methodological pathways
may claim a situated legitimacy.” (Gergen, Josselson, & Freeman, 2015, p. 2).
• In this interdisciplinary research perspective, different kinds of methodology will be invited in doing research, which is not set
a priori. This is different from the evidence hierarchy, in which a priori we say doing RCT is better than doing it differently.
• Topic dictates which methods are involved.
• Advantage of RDoC: multidimensional content (= ontology) asks for a pluralist research approach and mixed methodology
(= epistemology).
• Networks for major depression (MD) and generalized anxiety disorder (GAD):
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• Mental problems such as depression and anxiety are very much interrelated, so it doesn’t make much sense to investigate very
isolated problems.
EFFICIENCY VS EFFICACY DESIGNS
• RCT = efficacy research.

- Also severely critiqued
• Alternative: rise of efficiency research, which is also intervention research, but less strict inclusion criteria, bigger process focus and
often using multiple variables.
- Closer to what happens in clinical practice
PROCESS RESEARCH
• In pre-to-post you assume linearity (a mean line), but fluctuations are important!
- Process is often not at all linear
- Routine Outcome Measurement: not only pre and post treatment but also during treatment measuring!
• Clinically significant change ® Reliable Change Index (Jacobson & Truax, 1991):
- Recovery
- Improvement
- No change
- Deterioration
• Individual differences research ® e.g., within-group differences (cf., De Smet et al., 2019).
• Outcome variable not a priori ® personalized measurement.
- We have to allow people to formulate their own outcome variables – which are the things they want to see changed
over treatment – because that’s also much more goal-oriented and clinically relevant
NOICE, THE STORY OF ‘THE DATA’
• Voices in data.
• How participants can speak in self-report measures ® pre-structured, quantified and aggregated.
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- What is the participant allowed to say?

- Do participants understand instructions and quantification as we intended?
• Who is ‘the average patient’?
- The statistical mean is not a person
- A priori ® can we learn something not-anticipated?
- Clinical practice is messy!
• Voice = noise?
- Noise = clinical process!
- “Numbers are words too” (Truijens, 2019)
ONTOLOGY & EPISTEMOLOGY: VERSTEHEN
• The discourse of Verstehen – Understanding:

- Ontology = people make meaning of phenomena in their lived experience …
- Epistemology = … that want to understand by listening, thematically or discursively analyzing, and synthesizing
- Goal: understand how people understand phenomena
- Method: qualitative/mixed, inductive (i.c.m. deductive), bottom-up, narrative
MULTIDIMENSIONAL ONTOLOGY
• “All knowledge is in response to a question. If there were no questions, there would be no scientific knowledge. Nothing proceeds
from itself. Nothing is given. All is constructed.” (Bachelard, 1934)
• Paradigm of social constructivism:
- Meaning is socially constructed and mediated by language (Gergen, Josselson, & Freeman, 2015)
- Observation is never neutral ® researchers are always part of generated knowledge (e.g., by choice of methods, which
shape the knowledge obtained)
THE THEORY OF LISTENING
• Phenomenology/hermeneutics = how people make meaning, how we can understand each other’s meaning-making.
• Meaning is a constellation of interpretations, shaped by general, cultural, societal stories, but ultimately regard the way in
which the person understands these stories and is affected by them.
• Personal narratives as a starting point of understanding.
• Compare to core principles of the Recovery Paradigm (Slade, 2009):
- Giving primacy to values and preferences of individuals
- Complexity over simplification
- Social, relational, personal, dynamic
FACTUAL LISTENING …
• “Most contemporary psychiatrists would argue that their assessment involves a detached, factual listening to the patient’s
symptoms accompanied by a clear analysis of the person’s mental state … In this process, the experiences that trouble the patient
… are taken out of the patient’s own language and reformulated in psychiatric terminology … This process is carried
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out in an attempt to render psychiatric practice more scientific, the idea being that if we are to have a science of psychopathology,
we need a clearly defined language through which a scientific discourse can proceed. Without this, we are ‘limited’ to a level of
interpretation that is based only on personal narrative and locally defined meaning. A science of psychopathology demands
concepts that are universally valid and reliable. In other words, it demands a concern with the ‘forms’ of psychopathology.” (Bracken
& Thomas, 2005, in Slade, 2009, p. 9).
… VS GENUINE LISTENING
• Genuine listening is:

1. Contextualized
2. Meaning-rich
• Focus on content rather than on form
• “Meaning involves relationships and interconnections; a background context against which things show up in different ways … The
world of psychiatry, involving emotions, thoughts, beliefs and behaviors, is a world of meaning and thus context. Indeed, it is the
centrality of these twin issues of meaning and context that separates the world of the ‘mental’ from the rest of medicine …
Psychiatry is precisely delineated by the fact that its central focus is the ‘mental world’ of its patients. Meaning and context are thus
essential elements of the world of mental health and simply cannot be regarded as ‘inconvenient limitations’, issues than can be
ignored or wished away.” (Bracken & Thomas, 2005, in Slade, 2009, p. 9).
METHODOLOGY SHAPES KNOWLEDGE
• Ontology-epistemology impacts how we study mental illness, how we approach patients and how we offer treatments.
• Urge for reflexivity:
- You are just as human as the people you work with/study/treat
- Be aware of the impact of your worldview as mental health professional/researcher
ASSERTIVE OUTREACH
• Why? Some people don’t reach out for themselves.

- Social breakdown
- Severe neglect
- Unrecognized somatic problems
- Severe incident
HOW DO WE ENGAGE THESE CLIENTS INTO CARE?
• Go to the places where the people are.

• Gain trust.
• Try to find something that they’re motivated for.
• Try to ask what they want.
• Be careful with providing information, first try to understand what they want to hear.
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MOTIVATION PARADOX
• Classic assumption: problems ® distress ® motivation to seek help

• Motivation paradox in SMI: problems ® insight drops, negative experiences ® motivation drops
• We need assertive outreach to deal with the motivation paradox
ASSERTIVE OUTREACH IN PRACTICE
• Try to find common ground: something a person does want.

• Practical support first, diagnosis and treatment parallel.
• Skills needed: assertiveness, patience, creativity, seduction, persistence.
WHAT ARE ETHICAL DILEMMA’S USING ASSERTIVE OUTREACH?
ETHICAL DILEMMA’S
• Autonomy vs. social breakdown/self-neglect/health

• Autonomy vs. public safety
• The four principles of health care ethics:
1. Autonomy = in medicine, autonomy refers to the right of the patient to retain control over his/her body.
- A health care professional can suggest or advise, but any actions that attempt to persuade or coerce the patient into
making a choice are violations of this principle.
2. Beneficence = this principle states that health care providers must do all they can to benefit the patient in each situation.
- (= an act of charity, mercy, and kindness with a strong connotation of doing good to others including moral obligation)
3. Non-maleficence = this is probably the best known of the four principles, in short it means, “to do no harm”.
- (= to not harm)
4. Justice = the principle of justice states that there should be an element of fairness in all medical decisions: fairness in
decisions that burden and benefit, as well as equal distribution of scarce resources and new treatments.
• The basic definitions of each of the four principles of health care ethics are commonly known and used often in the English language,
but they take on special meaning when being utilized in a medical setting. All of these principles play a key role in ensuring optimal
patient safety and care.
WHAT CAN WE DO WHEN ASSERTIVE OUTREACH IS NOT SUCCESSFUL?
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• Coercion (Wet Verplichte GGZ) is allowed when:

- A patient suffers from a psychiatric disorder
- Causing risk or danger
- There is no alternative
DANGEROUSNESS CRITERIA
1. Danger to self (tel. 113 online)

2. Danger to others
3. Social breakdown
SUBGROUPS AT RISK FOR INVOLUNTARY ADMISSION
• Population risk for EIA for ethnic minority groups:

- Antilleans and Suriname’s most at risk (relative to Dutch: 3.6 and 3.0, respectively)
- Moroccans and Turkish second most at risk (relative to Dutch: 2.2 and 1.4, respectively)
EFFECTS OF COMPULSORY ADMISSIONS
• Dangerousness decreased in about two-thirds of the patients after court-ordered compulsory admission. It persisted, however, in a
substantial minority (approximately one-third).
NETWORK PSYCHIATRY
• Everybody lives in some kind of network.

• Macro vs. micro level.
• Involvement of significant others from the start!
GOALS
• Meaningful life for the patient.

• Prevent relapse.
FREQUENT PROBLEMS IN MENTAL HEALTH SERVICES
• On the level of the patient:

- No empowerment: passive acceptance of treatment
- Significant others not involved
- Discontinuity of care
- No connection/gaps between mental health and social services
• The ‘normal’ pathway through mental health services.
• 20-30% of patients in MHS have complex problems.
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VISION NETWORK PSYCHIATRY
• Network psychiatry = a way of working that brings together treatment and care (medical and social services) for people with
(complex) mental illnesses. The purpose is to increase chances of recovery.
LEADING PRINCIPLES
1. Working from one vision on recovery throughout the network

2. Patient takes responsibility for his treatment and ‘nothing about us without us’
3. Collaboration with significant others, from the start
4. Collaboration across psychiatric/medical and social domain
- On the level of the patient (micro)
- On the level of services
- Stimulating dialogue, making room for different perspectives
5. Continuity of care
- In network of services
- By organizing a stable (in)formal network around the patient
- Combine informal support system with formal support system
• Resource group meaningful roles: the resource group ensures that every member experiences the network as meaningful.
• Meaningful roles:
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• Don’t talk about the patient without the patient: no privacy problems
RESOURCE GROUP IN THE NETHERLANDS
• Resilient networks: in a network society, it is essential to sustain and create social relationships to ensure inclusion and prevent
exclusion.
• What are the essential components?
1. Client is director (nomination RG members, goals in the RG plan, chair, place, frequency of the meetings)
2. Structurally involvement and activation of the social environment (but client decides who): recovery happens within
daily life
3. Continuity of care: a person or group standing next to you, not leaving you along with your illness, at all times
• Why promising?
1. Own strengths and empowerment are the central components
- Goals? Nominated? Chair? Place?
2. Structurally involving significant others
- Creating “communicative situations” in and outside treatment
3. Continuity of care
- The research group as the constant factor during different steps
EFFECTIVENESS STUDY
• Quantitative: randomized controlled trial (RCT)

- Efficacy of the research groups:
Ø Client effects: empowerment, quality of life, social support
Ø Satisfaction client
Ø Well-being network
Ø Cost-effectiveness
• Qualitative: case study
- In depth information on the functioning and meaning of the research group method for clients and group members:
cooperation processes, personal perspectives, procedure for successes/setbacks, personal recovery process, etc.
THEME 5
LITERATURE
SLADE – CHAPTER 5: ETHICAL RATIONALE
• An orientation towards doing things to a person on the basis of professional views about their best interests does not promote
personal recovery.
• A better guiding principle is to orient action by clinicians as far as possible around the consumer’s goals, rather than professional
goals.
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WORKING WITH THE CONSUMER
• An orientation towards giving primacy to consumer-defined goals means the primary job of mental health services is to support the
person to progress towards their own life goals, not to provide treatment to meet clinical goals.
• Treatment is one important resource available from mental health professionals, but it should be a means to an end of the
individual’s life goals, not an end in itself.
• Clinical skills remain central. For example, the clinician may observe consistent links between a particular behavior of a patient and
an undesirable outcome. This is important information, which the professional should actively highlight in their work with the
patient, and support the person to engage in processing. But the difference is that this professional expertise is a resource to be
offered to the consumer.
• We suggest that there are two justifications for doing things to people against their will.
COMPULSION JUSTIFICAITON 1: BENEFIT TO SOCIETY
• Individual freedom vs. group freedom = the Apollonian-Dionysian spectrum.

• Societal values change over time, but at any one time they are invariant. Societal values are expressed as mandated behavioral
constraints. Most commonly in relation to mental health these constraints are that no one will be left to die (whether willfully
through suicide or unintentionally through self-neglect) or allowed to harm others. These behavioral constraints are non-
negotiable.
• One obligation placed on mental health professionals is to constrain behavior in order to uphold these societal values. It’s an
obligation which cannot and should not be ignored in a recovery-focused mental health system. These societally imposed, non-
negotiable constraints on behavior provide one ethical justification for compulsion.
• Distinguishing between intervening to benefit society and intervening to benefit the patient is helpful. Professional judgment
about whether the person has crossed over the societally mandated line remains central, but the line itself is not a professional
judgment.
• Since we cannot predict with certainty whether a specific patient will benefit from a compulsory intervention, we cannot know if it is
in the patient’s best interest. The justification for intervening is to uphold societal rules (which we can know), rather than for the
benefit of the patient (which we cannot know).
COMPULSION JUSTIFICATION 2: BEST INTERESTS
• Over and above societally mandated boundaries of behavior, there is an ethical justification to intervene in situations where there
is a risk of damage to the person’s life, health and well-being. The right to autonomy is reasonably over-ridden for some people
at some points in their life by considerations of best interests.
• This ethical justification for compulsion is paternalism: a clinician is acting paternalistically towards a patient when:
- His action benefits the patient
- His action involves violating a moral rule with regard to the patient
- His action does not have the patient’s past, present or immediately forthcoming consent
- The clinician believes they can make their own decision
• The idea of doing things to the patient in their best interest arises from a worldview that treatments are effective, and the privileged
access of health professionals to these effective interventions places an ethical requirement on those practitioners to provide
treatment. This has led to an often-unchallenged assumption that best interests are necessarily defined by professionals. There
are four challenges to this assumption:
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1. This ethical imperative is increasingly out of step with wider societal values, which instead emphasize personal
responsibility, informed choice and the right to self-determination. In other areas of life, there is a recognition that the
goals, aspirations and values of the individual should (in a moral sense) take primacy over those of the professional.
2. Health professionals no longer have sole access to information about treatments. Many patients have easy access
through the Internet to diverse sources of information about their mental illness.
3. The interests of people with mental illness have not been well served when responsibility for their well-being is assumed
by others.
4. It is consistent with modern capacity-based legislation.
- For example, in England and Wales, the Mental Capacity Act defines best interests as what the patient would have
chosen for themselves in the situation if they had capacity, which necessarily requires attention to the person’s goals,
values and preferences
• So we argue that:
1. Best interests are a justification for compulsion; AND
2. In a recovery-focused system, the closer to the individual’s view of their own interests the compulsion is, the more it can
be ethically justified.
• The best approach to identify the person’s view of their best interest is for the person themselves to state in advance what they
wish to happen when in crisis. Where this is not possible, a proxy decision-maker is the next best alternative. Since family or
friends will often know the person better than the clinician, professional judgment is not in general the best approach to identifying
what the person themselves would have chosen. If neither the individual’s preference nor a nominated proxy decision-maker is
available, then a clinical perspective on best interests may be the best remaining approach.
BALANCING ETHICAL IMPERATIVES
• Clinical judgment is a central approach to balancing conflicting values. In a recovery-focused service this is even more true,
because developing decision-making approaches in which the consumer is more empowered will create ethical dilemmas,
especially in relation to professional accountability where what the person wants is incompatible with the clinical perspective.
• If values need to be balanced, how is this done?
• One approach is values-based practice.
• Another approach is to draw from biomedical ethics. Four guiding principles:
1. Respect for autonomy: the importance of personal choice and self-determination is emphasized
2. Non-maleficence: there is an active focus on avoiding hopelessness and dependency
3. Beneficence: there is an equally active focus on providing effective treatments and interventions
4. Justice: there is support to exercise citizenship rights
• Actions justified on the basis of beneficence are balanced by the need to promote autonomy and support citizenship.
• A third approach is to use different values, such as avoiding overtreatment and therapeutic nihilism, to not be ashamed to say “I
know not”.
• The Soteria Project focused on the values expected of workers:
- Do not harm
- Do unto others as you would have done unto yourself
- Be flexible and responsive
- In general, the user knows best
- Valuing choice, self-determination, the right to refuse and informed consent
- Anger, dependency, sexuality and personal growth are acceptable and expected
- Where possible, legitimate needs should be met
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- Take risks
- Make power relationships explicit
• An emphasis on values positions the application of scientific knowledge as a means, not an end.
SLADE – CHAPTER 20: THE CONTRIBUTION OF RISK-TAKING TO RECOVERY
TWO TYPES OF RISK
• A focus on risk avoidance matters because people need to take risks to grow, develop and change.
• The conflation of these two uses of the term risk – something necessary and something to avoid – is unhelpful.
• In a recovery-focused service, there is a clear separation of the two meanings.
• Harmful risk relates to behaviors which are illegal or not socially sanctioned.
- Homicide
- Suicidal acts
- Anti-social and criminal behavior (assault, aggressive begging and theft)
- Personal irresponsibility (out-of-character promiscuity, financial profligacy)
- Self-harming patterns of behavior (violent partner choice, self-neglect)
- Relapse of mental illness
• Harmful risk is to be avoided.
• Positive risk-taking relates to behaviors which involve the person taking on challenges leading to personal growth and
development.
- Developing new interests
- Trying something you’re not sure you can achieve
- Deciding to act differently in a relationship
- Developing and consolidating a positive identity
• There is nearly always benefit from this – even if it all goes wrong; the learning is valuable.
• Resilience is developed through trying and failing – whether it be the common things like dating, employment, sex and religion,
or the idiosyncratic things like singing, archery, political activism or dress, we all learn from mistakes.
• Positive risk-taking – risk for a reason – will be needed to meet many recovery goals.
• Recovery-focused services are mindful of several issues in relation to risk:
1. Political domain: singling out people with mental illness for special risk management attention is not the actuarial place
to start, but the logical places (such as pubs and the school run) are not politically acceptable targets. Risk management
in mental health service is discriminatory.
2. Scientific domain: part of the academic system which is most focused on the issue (forensic mental health) has (as a
statement of fact rather than as a judgment) a vested interest in finding higher levels of harmful risk to others. Research
from this perspective inevitably amplifies the link, because researchers tend to find more of what they are looking for
than what they are not looking for.
3. The goal of eliminating harmful risk is both an illusion and damaging. It is an illusion stemming from the technical
rationality and Apollonian views of the world. The underpinning assumption is that if we had the right risk assessment
and management technologies, and the right clinical guidelines and rules, we could stop tragedies from happening.
Focusing on harmful risks creates the same issue as the approach of treating until well and only then getting on with life.
It fosters a cycle of disengagement (because the service is focused on what it thinks matters, rather than what the person
thinks matters) and compulsory intervention (to reduce risk).
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4. A clinical emphasis on risk management can be unintentionally counter-productive, by reducing skills in risk self-
management. People (whether they have mental illnesses or not) avoid acting on harmful impulses because they have
valued social roles they don’t want to jeopardize, a positive identity they don’t want to threaten, and the ability to
recognize and self-regulate emotions and their behavioral sequalae. A focus on avoidance of harmful risk through action
by clinicians creates a culture which may in fact reduce the extent to which people develop skills at taking responsibility
for their own actions.
5. Any approach to risk needs to be organizationally mandated, with responsibility held by the service rather than the
individual worker.
6. Risk management involves power, and so is an ethical issue. A recovery-focused mental health service must be prepared
to experience this uncomfortable tension, which in increasingly litigious societies may be especially anxiety-provoking.
A RECOVERY-SUPPORTING APPROACH TO RISK
• Features of a recovery-focused approach to risk management:

- Audited and organizationally supported systems are used to assess, develop and document actions focused on reducing
harmful risk. The consumer understands that these treatment goals are necessary for the professional – it is not
necessarily done for the consumer. The development of treatment goals is led by the professional.
- Audited and organizationally supported systems are used to assess, develop and document actions involving positive
risk-taking in the service of recovery goals. The professional understands that this is about the recovery goals of the
consumer – it is not necessarily agreed with by the professional. The development of recovery goals is led by the client.
- There is a greater focus on positive risk-taking than on avoiding harmful risk, because this is what develops risk
self-management skills.
- Actions to reduce harmful risks are as far as possible decided collaboratively with the consumer. Differences are
discussed openly, and where treatment goals need to be set because of the level of risk, this is acknowledged and
explained, and a consensual middle ground sought.
- Clinical decisions are where possible made by multi-professional teams rather than individual clinicians. This allows
for distributed responsibility for decision-making rather than anxiety being held by an individual worker.
THE STRENGTHS MODEL
• The service uses three care-planning types of document:

1. Professional treatment plan: treatment goals with a particular focus on medication, psychological treatments, early
warning signs and risk – akin to a treatment plan in a traditional mental health service. The advantages of separating
treatment plans from goals are (1) it makes more explicit the clinical responsibilities of the case manager – the treatment
plan is a component of care, but not the main work; and (2) it allows a more transparent negotiation about clinical versus
client priorities.
2. Strengths assessment: identifies the person’s strengths and current situation, which requires new skills in clinicians,
as they learn how to move from a deficit-focused mental state examination to skills in systematically identifying strengths.
The process leads to shifts in attitude, from ‘mental patient’ to ‘struggling and engaged person’.
3. Goal plan: led by the consumer and co-written with the case manager. It uses the individual consumer’s unique journey
of recovery as a springboard to identify goals, and to establish an agenda for the work with the case manager. An
important value is that all goals are recorded, regardless of whether they are ‘realistic’, because it communicates that it is
wrong for professionals to decide what is realistic.
• Workers in the service identify the following changes arising from the change in model:
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- Expectations: from the modest expectations of treatment to big dreams and ‘audacious’ goals
- Planning: from the case manager driving the plan to the consumer as the director of their own life
- Anxiety in the consumer: taking control of their own life can be scary and initially undesirable, but the intention is that
this anxiety reduces with increasing self-efficacy and self-esteem
- Anxiety in the case manager: empowering the consumer raises anxieties about risk, but the intention is that experiencing
the consumer as the director of their own life reduces the case manager’s anxiety, as they learn that they cannot be
responsible for the person’s life
- New ways of talking: the clinical discourse is less negative and more sophisticated, seeing the person in the round rather
than through a deficits filter
- New ways of being: different ways of working with the consumer are needed, which change the implicit power structures
and approaches to relating, e.g., ‘moving from an interrogation mode to a conversational mode’
- Medication: from being a high priority for the case manager to a more negotiated part of the support package
- Risk: from being a central element of the (only) treatment plan to being more obviously a care manager – rather than
consumer – priority
- Service links: from a primary focus on other mental health and social care services to a focus on mainstream community
services
• Risk is best addressed proactively. Lines of behavior crossed once are more easily crossed again, and stress is more easily contained
if diverted rather than allowed to grow to crisis point. From a recovery perspective, this means that harmful risks are reduced by:
1. Harnessing motivation through focusing on approach rather than avoidance motivation
2. Amplifying rather than minimizing risk self-management skills
3. Intervening early
• The development of recovery goals which involve positive risk-taking may therefore, paradoxically, reduce harmful risk. They
give someone a reason not to self-harm or self-neglect or be violent. Focusing on strengths creates possibilities, rather than
focusing on illness deficits, which creates a compliance and passivity context in which the anger of disenfranchisement and
disempowerment are more likely.
SLADE – CHAPTER 21: RECOVERY THROUGH CRISIS
• Labeling the experience as a relapse orients clinical attention towards symptom reduction, rather than the bigger picture of the
person. Labeling as a crisis has more helpful connotations, in which the experience also has potential to be a learning opportunity,
or a turning point.
COMPULSION
• A focus on personal recovery is not a charter to stand back and let tragedies happen because the person didn’t ask for or want help.
So compulsion during crisis is acceptable, if other options have been exhausted.
• The traditional service response to a person presenting in crisis has been hospitalization. However, many people experience
admission negatively. A US survey concluded: “Participants reported that [hospital] settings cause them to lose their living skills,
and re-traumatize them.”
FEATURES OF A RECOVERY-FOCUSED IN-PATIENT SERVICE
1. A safe normalizing environment: an open-door policy, a home-like environment, and containing fewer than 15 people.
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2. Recovery values: a shift from segregation to social inclusion, from paternalism to self-determination, and from “the dominance of
medical approaches … to more holistic approaches” (crisis is not only a time of risk, but an opportunity for personal growth).
3. Egalitarian culture: power structures are different, with more mingling between staff and patients. Talking, negotiating and self-
responsibility are emphasized.
4. A well-matched mix of people: a wide range of accessible staff from health and other backgrounds (e.g., peer support workers,
chaplains).
5. A broad range of competencies: both pharmacological and psychosocial expertise are available to all in-patients. A focus remains
on encouraging and amplifying self-directedness and self-advocacy, rather than “being compelled into dependency and compliance
or resorting to rebellion”.
6. A broad range of interventions: available forms of support include medication, complementary treatments such as homeopathy,
physical treatments such as massage, self-help approaches and psychosocial approaches such as counseling, practical assistance,
peer support or therapeutic communities.
• A recovery-focused approach to crisis has four aims:
1. To prevent unnecessary crises
2. To minimize the loss of personal responsibility during crisis
3. To maintain hope during crisis
4. To support identity in and beyond the crisis
1. PREVENTING UNNECESSARY CRISES
• The best way of reducing the likelihood of crisis is through the development of self-management skills. These lead to agency,
empowerment and the resilience to cope with set-backs. An important type of self-management skills is the ability to recognize
and respond to the symptoms of mental illness.
• Clinical skills are needed to communicate two things to the consumer:
1. Not all of life’s bumps are indicators of potential relapse. Everyone has good and bad days – and the goal is to create a
virtuous cycle by recognizing strengths and achievements, rather than a vicious cycle of hyper-vigilance to prodromal
symptoms.
2. Relapse, in the sense of going backwards, is normal. Set-backs are normal and necessary in life – they are a sign of health,
not illness. The response to these set-backs is the critical factor.
2. MINIMIZING THE LOSS OF PERSONAL RESPONSIBILITY DURING CRISIS
• A key approach to reducing loss of autonomy is the use of advance directives. These allow people to express in advance their
preferences for what they want to happen during a future crisis. They can take many forms, but broadly fall into two categories:
1. Advance instructions including statements of acceptance or rejection of certain treatments
2. Identification of a proxy decision-maker to make decisions on the person’s behalf
• Advance directives offer many pro-recovery features:
- Self-direction
- Empowerment
- Strengths-based assessment
- Promoting respect for the individual’s wishes
• Barriers:
- Intrinsic complexity (e.g., legal language, finding witnesses, filing with providers)
- Systematic barriers impacting on provider access to the advance directive when the person presents in crisis
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- Ethical dilemma of being asked to follow the advance directive if they do not perceive this as in the person’s best interest
• Advance directives are what makes a partnership relationship possible during crisis. Therefore, they need to be a joint
understanding, in which the consumer educates the clinician about their preferences, and the clinician provides empirical, ethical
and procedural information to inform the consumer’s decision-making.
• Other approaches to reducing the likelihood of disempowerment during crisis:
- Shared care agreements
- Patient-held reports
• There is RCT evidence to support their use, and they all orient the individual towards taking responsibility for their own lives and
what happens to them in crisis.
• A more nuanced view of capacity as multi-dimensional and continuous has the advantage of pointing to a goal of maximizing what
the person can decide for themselves during crisis. Being involved in apparently small day-to-day decisions can provide a way of
sustaining the personal responsibility muscle during crisis.
- Reinforces success through praise (e.g., for getting up when this is a struggle) is an important intervention
3. MAINTAINING HOPE DURING CRISIS
• The clinician’s illusion makes it difficult to see crisis as an exception rather than the norm. for clinicians who work only with people
in crisis, this illusion expresses itself in two ways:
1. If the clinician only sees people with a diagnosis of schizophrenia when they are in crisis, then the available evidence will
suggest that schizophrenia is always associated with high levels of distressing, disabling and unmanageable
symptoms. Addressing this aspect involves exposing the clinician to people with a diagnosis of schizophrenia who are
not in crisis, either by bringing role models into the crisis setting or taking the clinician out.
2. If the clinician only sees an individual during crisis, then it is difficult not to form a view that this is how they are all the
time, leading to therapeutic pessimism, and a decontextualized understanding of the person which underestimates their
strengths and normal self-management skills. Time-lines is an approach to putting the crisis into a temporal context.
Another approach is for clinicians to work with an individual both during crisis and during the rest of their life, rather than
having separate crisis teams.
4. SUPPORTING IDENTITY IN AND THROUGH CRISIS
• Relationships are of paramount importance during crisis. The development of a partnership relation as soon as possible is
central. How is this done? Peers can be particularly skilled at making this kind of connection.
• Key recovery-promoting features are attention to environment, trying to keep the person in their life, and a balancing of the
need for safety and the opportunity that being in crisis presents to learn from the past and to re-orient future plans.
GREENHALGH – NARRATIVE BASED MEDICINE IN AN EVIDENCE BASED WORLD
SUMMARY POINTS
• Even ‘evidence-based’ clinicians uphold the importance of clinical expertise and judgment.
• Clinical method is an interpretive act which draws on narrative skills to integrate the overlapping stories told by patients,
clinicians, and test results.
• The art of selecting the most appropriate medical maxim for a particular clinical decision is acquired largely through the
accumulation of ‘case expertise’ (the stories of ‘illness scripts’ of patients and clinical anecdotes).
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• The dissonance we experience when trying to apply research findings to the clinical encounter often occurs when we abandon the
narrative-interpretive paradigm and try to get by on ‘evidence’ alone.
THE LIMITS OF OBJECTIVITY IN CLINICAL METHOD
• Evidence supports the claim that doctors do not simply assess symptoms and physical signs objectively: they interpret them by
integrating the formal diagnostic criteria of the suspected disease (that is, what those diseases are supposed to do in ‘typical’ patients
as described in standard textbooks) with the case specific features of the patient’s individual story and their own accumulated
professional case expertise.
DIAGNOSIS: EVIDENCE OR THE INTERPRETED STORY?
• The ‘truths’ established by RCTs cannot be mechanistically applied to individual patients (whose behavior is irremediably contextual
and idiosyncratic) or episodes of illness.
• The generalizable truth that we seek to glean from research trials pertains to the sample’s story, not the story of individual
participants. There is a serious danger of reifying that population story – that is, of applying what Whitehead called the fallacy of
misplaced concreteness – and erroneously viewing summary statistics as hard realities.
- Misplaced concreteness is also an apt description of the dissonance we experience when we try to apply research evidence
to clinical practice
- Hunter has suggested that the reason why medical practice cannot constitute a science is that medicine lacks rules that
can be generally and unconditionally applied to every case, even every case of a single disease
STORIES WITHIN STORIES
• The ‘text’ that constitutes the diagnostic encounter, and which distinguishes it from other human narratives or modes of
communication, is a story about the ‘person as ill’.
• This in turn integrates four separate secondary texts:
1. The experiential text – the meaning the patient assigns to the various symptoms, deliberations, and lay consultations
in the run up to the clinical encounter
2. The narrative text – what the doctor interprets to be ‘the problem’ from the story the patient tells – the traditional
medical history
3. The physical or perceptual text – what the doctor gleans from a physical examination of the patient (using the ill-
defined but recognizable set of skills that have been called ‘practical reason’)
4. The instrumental text – what the blood tests and x-rays ‘say’
• According to Leber, the search for the ‘objective’ analysis of diagnostic tests is a flight from interpretation, and one that is
doomed to fail.
CONCLUSION
• Far from obviating the need for subjectivity in the clinical encounter, genuine evidence-based practice actually presupposes an
interpretive paradigm in which the patient experiences illness in a unique and contextual way.
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• Furthermore, it is only within such an interpretive paradigm that a clinician can meaningfully draw on all aspects of evidence –
his or her own case-based evidence, the patient’s individual and cultural perspectives, and the results of rigorous clinical research
trials and observational studies – to reach an integrated clinical judgment.
THE ROLE OF THE PSYCHOLOGISTS
EVIDENCE-BASED PRACTICE (EBP)
• People have a right to ‘best practice’ care.

• Best practice care:
1. Based on scientific support (EBT)
- EBP is not the same as EBT ® EBT is part of EBP
2. Based on clinical training and experience (your role as a psychologist)
- You as clinical professional are just as much part of EBP ® clinical reflexivity as imperative for good practice
- You have to balance different sources of information (science, experience, ethics)
3. Based on ethics
- Ethics of clinical practice
- Ethics go beyond the rules and regulations
EBP > EBT
• The APA Task Force defined EBP as “the integration of the best available research with clinical expertise in the context of patient
characteristics, culture, and preferences.”
• You as a clinical expert balancing out scientific research and clinical expertise and the patient characteristics.
• Practitioners must use their clinical judgment and expertise to determine how to implement, and if necessary, modify a given
approach for a particular client, in a particular circumstance, at a particular time.
• EBT = focused on the general, universal.
• EBP = focused on the individual (translating the universal to the particular).
- Dissemination = we translate/transfer this to clinical practice
- This is not one-to-one translation: it never works the same way!
- Actively involves a translation, in which you as a psychologist play a vital part!
ETHICS AND EVIDENCE-BASED MEDICINE
• EBM starts from a moral position, based on values:

1. Health is a good that we should pursue.
2. If we should pursue health, then we should pursue the most effective means of pursuing health (we have to do it in the
most effective way).
3. We should pursue EBP.
• This stems from utilitarian ethics: greatest happiness for the greatest number ® allocation of means.
- You allow that not every person will arrive at this greater happiness as long as most people do
• Rather than deontological ethics: meet needs of every individual in the best possible way.
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- We don’t allow one person to be maltreated even though it could give us greater happiness for a greater amount of
people
• This is not to say that deontological and virtue ethics commitments are dismissed; however, the central purpose of EBM practice is
not to foster our virtues or enhance our actions or duties towards patients.
- If we have to choose, we will go for the greater good rather than every person’s individual needs
• EBM’s approach to decision-making gives researchers, first and foremost, the authority to define what constitutes improved health
or decreased harm to health. It is researchers who typically choose the outcomes under investigation in medical research, and it is
these outcomes that EBM seeks to achieve.
- So, one group of researchers has quite a large role in deciding what outcomes would be considered healthy
• The core task in psychiatric EBP is to “determine who can be thought of legitimately as having a psychiatric disorder. This task
requires that psychiatrists possess shared and objective standards of what constitutes a psychiatric disorder.”
- We want psychiatrists to work from the same basic principle, so we need some standards
• Two problems:
1. They rely primarily on self-reporting of symptoms. Apart from observing patients’ behaviors, there are few objective
methods of assessing most psychiatric disorders, which increases the likelihood that psychiatric diagnoses contain value
judgments – rather than scientific judgments – about what is normal and what is abnormal (we enter the domain of
medical ethics).
2. How to draw the line between normal and abnormal in domains that exist along a continuum and where the range
of normal is wide?
ETHICS OF CLINICAL PRACTICE
• Foucault: The Birth of the Clinic (1963/1986).

• Power explained via the panopticon (Jeremy Bentham) – originally made for a prison but also used for schools and psychiatric
hospitals.
• Surveillance tower in the middle: not seen on the outside whether someone is in there or not ® there is always a possibility that
you’re being watched, so there may be punishment.
• Registration: for every single person, who is behaving badly.
• Discipline via surveillance and registration.
• Metaphor for how psychiatric diagnosis works.
• The power of analysis:
- Identification in dichotomy (e.g., normal/abnormal)
- Every individual is marked (= individualization)
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- As basis for exclusion

- Collective system: every person who identifies as ‘normal’ substantiates the dichotomy normal/abnormal (by calling
yourself normal, you allow the possibility of someone else being called abnormal)
- Internalizing effect!
DICHOTOMIES AND ETHICAL DIFFERENTIATION
• “The language of clinical psychology remains the language of medicine and pathology – what may be called the language of the
illness ideology.”
1. Terms such as symptom, disorder, pathology, illness, diagnosis, treatment, doctor, patient, clinical and clinician are used.
2. These terms emphasize abnormality over normality, maladjustment over adjustment, and sickness over health (based on
differentiation, time-specific)
3. They promote the dichotomy between normal and abnormal behaviors, clinical and nonclinical problems, and clinical
and non-clinical populations (based on differentiation, time-specific)
4. They situate the locus of human adjustment and maladjustment inside the person rather than in the person’s
interactions with the environment, or in sociocultural values and sociocultural forces such as prejudice and opposition
(based on identification, individual)
5. Finally, these terms portray the person who is seeking help as passive victims of intrapsychic and biological forces beyond
their direct control who therefore should be passive recipients of an expert’s ‘care and cure’ (leads to exclusion,
dependence)
• To set apart from the bigger group (the tails of the normality distribution).
• The core point: by this system we come at the point that we find ourselves as experts entitled to take over from people, to set them
apart, to tell them, “You’re not OK, therefore, I gain the right to do something for/to you”. This changes autonomy for people, and
puts them in a different (lower) position in a hierarchy, depending on the people higher in the hierarchy.
THE CASE OF ‘DIFFICULT PATIENTS’
• “The fact that current treatments are not a good fit for these patients was seen as a major problem. Some participants [health care
professionals] stated that they believed that these patients would cease to be ‘difficult’ if they could participate in a program
designed to meet their needs. Participants partly blamed the lack of suitable treatments on poor [unidimensional] diagnosis of
these patients. They also criticized the term ‘difficult patients’ because it may invoke half-hearted care, or what
participants termed ‘pampering and dithering’.” (Koekoek et al., 2009, p. 696).
• The use of the term ‘difficult patients’ has a consequence of getting half-hearted care.
• The term is a process of identification (good patients vs difficult patients), which leads to the approach of exclusion.
TREATMENT RESISTANCE
• No more treatment options.

- Better to talk about ‘not responding’: recurrence of complaints (chronicity)
• Unwilling, resistant patient.
- People didn’t adhere to what they got: when it does not fit/is not sufficient/is not difference making
• People get blamed for not responding or adhering to the protocol!
• By this term, we start to identify people as being in a certain group.
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- Dichotomy: responders/resisters
- Four key recovery pillars: identity
- We don’t make identity alone, we also get identities ‘put’ on us by a whole societal context
- Diagnosis: giving another identity to adhere to
- Talking about ‘difficult patients’ or ‘treatment resistant patients’ is putting an identity on patients in the field
IMPACT OF WORDS ON IDENTITY
• “Words are not transparent windows, but rather they convey meanings.”
• Slade: “Being given a diagnosis brings the short-term relief of understanding, but if it becomes a dominant identity then it creates
an engulfing role which can destroy hope for a normal life.”
• Reification (Hacking, 2000): you identify with your description.
- Can be either positive or negative
• “Accordingly, constructing a coherent sense of self, that expands beyond the illness and is founded upon non-stigmatic anchors,
is a major focus in the recovery paradigm.”
- ‘Rewrite your identity’
NARRATIVE FOR RECOVERY
• “The concept or narrative identity presumes that the stories we tell about ourselves convey who we are and how we conceive
ourselves, others, and the world. Narratives do not only reflect identities, but also create them. Re-building a positive sense of
identity in the face of SMI is thus primarily a process of re-storying the self.”
- Identity is flexible, you can easily rescript it
- Stimulating people to actively look for another narrative (or expressing/understanding themselves) may facilitate this
recovery process
• “By connecting life events into a temporal whole, we make sense of how we evolved from what we were in the past to what we
are in the present. In this understanding, the meanings of events and facts (e.g., the illness) are constantly revised and ‘re-
written’.”
- Narrating is important because you come up with a new story for yourself in which you also may change the meaning of
this whole illness process
NARRATIVE AS BASIS FOR EVIDENCE
• “Narrative is not some second-rate homely account, to be disregarded once science has caught up. It is the closest we can come to
the unknowable reality of the experience of other people.”
• “Moreover, empirical evidence indicates that as people move towards recovery, both narrative content and form change.”
- Language as ‘outcome measure’?
VALUES-BASED PRACTICE
• Our psychiatric practice is not value-free! Even though we work really hard to work with communication tools, treatment protocols,
diagnosis measurements, but this is still very strongly embedded in values.
• The ‘values-blindness’ principle: careful attention to language use raises awareness of values.
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- Psychology is language-based
• The ‘space of values’ principle: ethical reasoning is employed to explore differences of values, not to determine ‘what is right’.
THE PLACE OF RECOVERY IN EBP
• How to integrate the recovery paradigm and EBP?

• EBP = person-centered AND evidence-based.
• You as a mental health professional are vital to balance evidence, training and experience, and interpersonal curiosity and openness
to the other person.
THERE IS NO PARADOX (GREENHALGH)
• “Evidence supports the claim that doctors do not simply assess symptoms and physical signs objectively: they interpret them by
integrating the formal diagnostic criteria of the suspected disease (that is, what those diseases are supposed to do in ‘typical’
patients as described in standard textbook) with the case specific features of the patient’s individual story and their own accumulated
professional case expertise.”
• “The material of traditional medical practice and teaching, is unrepresentative of the average case. Misplaced concreteness is also
an apt description of the dissonance we experience when we try to apply research evidence to clinical practice.”
• Dr. Jenkins’ strange hunch: “Taken alone, neither best research evidence nor the intuitive response to a short unusual story would
have saved the patient, but the integrated application of both has produced a feat we would all be proud to replicate just once
in our clinical careers.”
CONCLUSION
• Appreciating the narrative nature of illness experience and the intuitive and subjective aspects of clinical method does not require
us to reject the principle of evidence-based medicine. Nor does such an approach demand an inversion of the hierarchy of evidence
so that personal anecdote carries more weight in decision-making than the RCT. Far from obviating the need for subjectivity in the
clinical encounter, genuine evidence-based practice actually presupposes an interpretive paradigm in which the patient
experiences illness in a unique and contextual way. Furthermore, it is only within such an interpretive paradigm that a clinician can
meaningfully draw on all aspects of evidence – his or her own case-based experience, the patient’s individual and cultural
perspectives, and the results of rigorous clinical research trials and observational studies – to reach an integrated clinical
judgment.
- So, evidence-based practice is already narrative-based practice!
CONCLUSION OF THIS LECTURE
• The role of the psychologist is to reach an integrated clinical judgment that is in the best interest of the person, also person-
centered, but based on an integration of what you see happening, what the person sees happening, the needs and wants and
wishes of the patient, and what evidence can say about that.
• Not one part that is dominant, it’s the integration of this whole that will make up an integrated clinical judgment.
YOUR PLACE IN RECOVERY AND EBP
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• Urge for reflexivity:

- You are just as human as the people you work with/study/treat
- Be aware of the impact of your worldview as a mental health professional/researcher
• Listen on different levels, be open for the story-in-the-story ® advantage of being a young mental health professional!
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lOMoARcPSD|10207131

4.3C Severe Mental Illness in Urban Context Course

StudeerSnel wordt niet gesponsord of ondersteund door een hogeschool of universiteit

People using mental health services lie on a spectrum:

AIMS OF THE BOOK

2. To crystallize exactly what personal recovery means.

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This is addressed in two ways:

NEW GOALS, VALUES, KNOWLEDGE AND WORKING PRACTICES

WHAT IS MENTAL ILLNESS?

• The starting point for understanding mental illness is as a subjective experience.

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CLINICAL MODEL 1: BIO-MEDICAL

The biomedical model of illness involves two key assumptions:

• Neither assumption is universally true in relation to mental illness.

CLINICAL MODEL 2: BIO-PSYCHO-SOCIAL

Domain Dominant concept/approach

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Proximal aim of treatment Symptom reduction, functional improvement

These assumptions do not fit reality in four ways:

MISMATCH 1: MENTAL ILLNESS IS NOT (ONLY) CAUSED BY DISTURBED HOMEOSTASIS

• The Jasperian distinction between understanding and explaining is crucial:

MISMATCH 2: DIAGNOSIS DOES NOT ‘CUT NATURE AT ITS JOINTS’

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MISMATCH 3: ASSESSMENT PROCESSES CREATE STIGMA

• Clinical assessment should cover four dimensions:

MISMATCH 4: TREATMENT DOES NOT CURE

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CLINICAL MODEL 3: COGNITIVE

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• Advantages of this approach:

• Three levels of impact:

• Advantages of a social disability model in the domain of work and employment:

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• Diversity models challenge three embedded assumptions:

ADJUDICATING BETWEEN MODELS

Clinical model Disability model Diversity model

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• Five key recommendations:

WESTEN, NOVOTNY & THOMPSON-BRENNER – THE EMPIRICAL STATUS OF EMPIRICALLY SUPPORTED

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RETELLING THE STORY: THE ASSUMPTIONS UNDERLYING ESTS

• ESTs share a number of characteristics:

1. PSYCHOLOGICAL PROCESSES ARE HIGHLY MALLEABLE

2. MOST PATIENTS HAVE ONE PRIMARY PROBLEM OR CAN BE TREATED AS IF THEY DO

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3. PSYCHOLOGICAL SYMPTOMS CAN BE UNDERSTOOD AND TREATED IN ISOLATION FROM

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THE FUNCTIONS OF MANUALIZATION

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DISMANTLING THE SCIENTIFIC TESTING OF TREATMENT PACKAGES

SCIENCE AND PRESCIENCE: SELECTION OF TREATMENTS TO TEST AS A SOURCE OF BIAS

• Another significant caveat is the problem of determining which treatments to test.

INCOMPATIBILITIES BETWEEN THE REQUISITES OF EXPERIMENTAL DESIGN AND PRACTICE

RETELLING THE STORY: A REEXAMINATION OF THE DATA SUPPORTING ESTS

MULTIDIMENSIONAL META-ANALYSIS: AGGREGATING A RANGE OF INDICATORS OF OUTCOME

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EFFICACY OF ESTS FOR COMMON PSYCHOLOGICAL DISORDERS: A META-ANALYTIC REASSESSMENT