The role of social factors in dissociation and threat processing in psychosis

Context of the research
Psychotic conditions (i.e. experiencing symptoms such as hearing voices or delusions) have some of the most severe and enduring mental health outcomes, such as high suicide rates, stigmatisation, disengagement from society, loss of economic productivity, and poverty. Therefore, studying the psychological and social processes that aid or hinder recovery from psychosis has the potential to contribute to treatment and service developments with both social and economic impacts. Psychological research has shown that people with psychosis process experiences of threat in a biased way, such as being more likely to remember and pay attention to threat-related information than people without psychosis. Other studies have shown that traumatic experiences can cause psychotic symptoms, which may be explained by the way the mind responds to extreme threat. Repeated experiences of trauma means that the mind both becomes more alert to threat, and responds to even minor threats by dissociating and even hallucinating.

Aims of the research
The particular threat experiences of interest in this research are socially-based threats, such as those linked to stigmatisation (i.e. social disapproval towards a person based on characteristics that differ from social norms) and shame. Psychotic conditions, particularly schizophrenia, carry severe social stigma, and many of those diagnosed will internalise this stigma to experience shame (i.e. developing negative attitudes towards themselves). This research will test out whether these socially-based threat experiences can actually maintain people's vulnerability to psychosis through activating the brain's threat-response system. The research will also investigate the feasibility of a therapy called Compassion-Focused-CBT for psychosis (CF-CBTp) that aims to calm and regulate an overactive threat-response system by building internal feelings of safeness and affiliation. Compassion-focused therapies are designed to stimulate the brain's oxytocin-opiate systems, which are the natural systems of hormones and neurochemicals that evolved to process experiences of caring, soothing, and affiliation. There is already some evidence that group-based compassion-focused therapies are potentially beneficial for people recovering from psychosis.

Importance of the research
This research may have implications for understanding how psychotic states arise and are maintained. In terms of treatment, it may inform the direction of specific therapy designs and the general culture of psychosis services, which are both important for reducing stigma and shame and promoting external and internal experiences of social safeness. These research findings could potentially add scientific weight to the recent NHS vision outlined by chief UK nurses for a culture of compassionate care.

Researcher and outline of studies
The research will be carried out by Dr Charles Heriot-Maitland at the Institute of Psychiatry, King's College London. Three studies will investigate the role of social threat in psychosis by collecting and analysing self-rated assessment measures from participants in different populations, with and without mental health service involvement. Each study with use a different research method to test out the role of these social factors from different angles. A fourth treatment study will investigate the feasibility of CF-CBTp by providing the therapy with a Clinical Psychologist to a series of people in NHS psychosis services.

Aims
To investigate the role of social-rank related threats, such as those linked to stigmatisation (external threat) and shame (internal threat), on outcome in psychosis, and to test the feasibility of a psychological intervention for psychosis designed to target the regulation of social threat processing.

Objectives
To inform bio-psycho-social models of psychosis, and to advance psychological treatments for people with psychosis.

Methodologies
1. An online questionnaire study will test the moderating effects of social-rank threat on the relationship between dissociative traits and psychotic states in a healthy population. Online data will be collected from 700 participants, with a 6-month follow-up.
2. An experience-sampling method (ESM) study will test the daily-life causal relationships between social-rank threat and psychotic symptoms in clinical (n=20) and non-clinical (n=20) groups matched for dissociative traits. Data will be collected at 10 points per day for 6 days.
3. A longitudinal study will test the moderating effect of social-rank threat on the longitudinal relationship between dissociative traits and psychotic states in a 'non-clinical in crisis' population with psychotic-like experiences. 29 participants will provide data at T1 (in crisis), T2 (3 months) and T3 (6 months).
4. A case series study (n=18) will test the feasibility of delivering and evaluating Compassion-Focussed-CBT for psychosis which aims to regulate threat processing, with a positive impact on psychotic symptoms.

Opportunities
This research will aid the integration of cognitive approaches to psychosis with models of trauma processing and compassion-focused approaches, which have firm roots in neuroscience, and will provide opportunities for future psychological and neurological explorations of interpersonal factors and threat processing in psychosis. The treatment study will provide information on parameters for the design of future studies to evaluate efficacy.

This research will potentially benefit people with psychosis, their families and carers, and those providing their treatments. These benefits are most likely to occur through implications for future developments in therapies and services.

Beneficiary 1: NHS clinicians, service users, and families
At the level of therapies for people with psychosis, this research will have implications for the theoretical understanding of psychosis that informs the design and enhancement of therapies. If social-rank threat variables are found to moderate dissociative and psychotic processes, there will be implications for the development of family and group therapies that reduce external social threats, and for individual therapies that cultivate internal experiences of affiliation and safeness by building capacity in the oxytocin-based affect system that evolved for care-giving survival needs. Direct implications for individual treatment design may arise from the clinical study, which will test the acceptability and feasibility of a CF-CBTp intervention, and potentially inform the design of a future efficacy study.

With the supervisory and collaborative support of some prominent figures in UK Clinical Psychology, there may be further potential for this research to influence future directions in therapies, which down the line, may have a bearing on national treatment guidelines. My host Department has an excellent record of influencing NICE guidelines on the psychological treatment of psychosis. Making an impact at this level would certainly have implications for national health and wealth, especially when the population in question have some of the most severe and enduring mental health outcomes, such as high suicide rates, stigmatisation, disengagement from society, loss of economic productivity, and poverty (Bentall & Morrison, 2002).

Beneficiary 2: NHS organisations
At the level of services, positive findings from this research would have implications for promoting a culture of compassionate care and initiatives to tackle stigma (both in services and the wider society). Compassionate care is currently at the heart of NHS agenda and strategy, driven by two recent reports: Care and compassion by the NHS Ombudsman (2011) and The Point of care: Enabling compassionate care in acute hospital settings by The King's Fund (2009). Also, the newly published professional vision by the NHS Chief Nursing Officer and Nursing Director (2012) is entitled Developing the culture of compassionate care. Should the predicted research findings be obtained, they could add scientific backing to these strategies by highlighting the direct role of service cultures and treatment contexts in the underlying mechanisms of psychotic symptoms.

Beneficiary 3: Non-statutory sector
There are also potential beneficiaries in the non-statutory sector, particularly organisations working to de-stigmatise psychosis and encourage social acceptance and inclusion. If the proposed research demonstrates, as predicted, the importance of social-rank threat in the course of psychotic symptoms, organisations, such as Mind and Intervoice, may benefit from a greater scientific case, in addition to the humanitarian cases, in promoting and attracting funds to their work. Intervoice has already recognised my earlier work in this area by awarding their Paper of the Year 2012 to my research highlighting social and contextual differences between clinical and healthy populations with psychotic-like experiences (Heriot-Maitland et al, 2012).