Psychotherapies for the Psychoses

Theoretical, Cultural and Clinical Integration

John F. M. Gleeson, Eóin Killackey, Helen Krstev

• Publisher: Routledge
• Year: 2007
• ISBN:
  9781134127504
• Edition: 1
• Topic: Psicologia
• Subtopic: Psicoterapia

Can biological and psychological interventions be integrated in the treatment of psychosis?

Throughout the world, access to psychotherapeutic and psychosocial treatments for the psychoses varies significantly, with many people diagnosed with psychotic disorders receiving only medication as treatment. Psychotherapies for the Psychoses considers ways that this gap can be bridged through theoretical, cultural and clinical integration.

The theme of integration offers possibilities for trainees and experienced mental health professionals from diverse orientations and cultural perspectives to strengthen alliances for tackling the gap in availability of treatments. In this volume contributors discuss:

• Theoretical integration across the psychological therapies for psychoses
• Global perspectives on psychosocial approaches for psychoses
• Integrating psychotherapeutic thinking and practice into 'real world' settings.

Psychotherapies for the Psychoses explores different approaches from a variety of theoretical perspectives, providing significant encouragement for mental health practitioners to broaden the range of humane psychotherapeutic possibilities for people suffering from the effects of psychosis.

Chapter 1
Integration and the psychotherapies for schizophrenia and psychosis

Where has the ‘new view’ of schizophrenia taken us?

John F. M. Gleeson, Helen Krstev and Eóin Killackey

Chapter overview

In this introductory chapter we have undertaken a selective review of contemporary integrated aetiological accounts of psychosis. We include a detailed description and critical analysis of the stress vulnerability models (SVM) of psychosis. We acknowledge their limitations, but argue that these models have provided a valuable theoretical platform for the development of integrated treatments in psychosis and for multidisciplinary research efforts which could expand our understanding of psychosis beyond classical linear models of aetiology. However, we lament the gap between the vision, offered in the 1970s, via the so-called ‘new view’ of schizophrenia and its translation into both practice and research. We conclude that more needs to be done, especially by the leaders of psychosocial research, to actualize the vision of integration.

Levels of integration

Before providing an account of the history of recent integrated perspectives of psychosis, it is worthwhile to consider the possible levels at which integration can occur in relation to treatment. One conceptual framework was provided by Norcross and Goldfried (2005) in the second edition of their edited volume on integration in the psychotherapies. They suggested that integration can be achieved, first, at the micro-level of technique (i.e., technical eclecticism); second, by considering the interactions and synergies between separate treatment approaches (e.g., psychotherapy and psychopharmacology); or third, by blending theoretically diverse approaches into integrated models of therapy (e.g., cognitive analytic therapy or dialectic behaviour therapy). An integrative ‘perspective’ in the psychotherapies has also been described, which has been characterized as a flexibility and inclusiveness in attitude to treatment approaches. Additionally, the term ‘integrated approaches’ has been used as a collective description for all of these efforts (Greben, 2004).

Integration in schizophrenia and the psychoses

Attempts to integrate aetiological explanations and treatments in schizophrenia have an extensive history. These efforts appear to be underpinned by a belief that interdisciplinary research endeavours provide the best hope for furthering the understanding of psychoses, and, that patients and their families will achieve substantial benefits from integrated treatments. We believe that these efforts can be broadly described as consistent with the ‘integrative perspective’. Additionally, we can point to some examples of technical eclecticism contained in individual psychotherapeutic interventions described in the research literature (Hogarty et al., 1995). However, it is noteworthy that so little consideration has been given in the psychosis literature as to how to integrate across treatment approaches (Gabbard, 2006), and that examples of coherent, theoretically blended models of psychotherapy in psychosis are so rare (Kerr et al., 2003). As an illustration of this state of affairs, it is noteworthy that Norcross and Goldfried’s (2005) extensive volume does not contain a single reference to the application of integrated psychotherapy to psychosis or schizophrenia.

The Melbourne ISPS debate: our starting point for a focus upon integration

At the Fourteenth International ISPS symposium in Melbourne in 2003, a panel of psychiatrists and psychologists, including Professor Henry Jackson, Dr Brian Martindale, Dr John Read, Professor Richard Bentall, Dr Wayne Fenton and Dr Ann-Louise Silver debated the question: ‘Can biological and psychological interventions be integrated in the treatment of psychosis?’ This discussion provided a starting point for this chapter, and the volume. Arguing for the affirmative Dr Brian Martindale argued:

the simple answer to the debate is that they can be integrated. However the most important point is that psychological therapies are very rarely offered to any substantial degree and are usually done in such a skewed fashion dominated by biology.

Although on the opposing team Dr John Read opened his address also arguing that integration was desirable but that political and economic realities actively worked against it. He went on to argue that:

The claim that we already have integration is frequently made, with reference to the ‘stress-vulnerability’ or ‘stress-diathesis’ paradigm. This is often equated with the so-called ‘bio-psycho-social’ model. This model, as currently applied, is actually a colonization of the psychological and the social by the biological.

These arguments lead us to an examination of the history of the ‘stressdiathesis’ paradigm in psychosis—specifically to reconsider its appropriateness as an integrative theoretical perspective, and to a consideration of the ‘application’ of the ‘new view’ of psychosis.

The ‘new view’

The thirtieth anniversary of Zubin and Spring’s (1977) ‘new view of schizophrenia’ is an appropriate vantage point from which to reflect upon its impact. Having emerged contemporaneously with Engel’s (1977) broader critique of reductionistic biomedicine and his alternative ‘biopsychosocial’ model, Zubin and Spring’s (1977) model remains the most influential example of an integrated model of the aetiology of schizophrenia—nearly 700 citations of their article at the time of writing is indicative of its popularity within the international research community.

Few contemporary leading researchers in the field of psychosis would argue for a unifactorial account for the aetiology of schizophrenia. Unfortunately, this consensus and enthusiasm for integrated aetiological explanations has not been translated into access to integrated treatments—we would concur with Brian Martindale and John Read that even across wealthy industrialized nations treatments are too often narrowed to biological options, or psychosocial interventions are adjunctive afterthoughts to antipsychotic medication. Data from our own country, Australia, provides a case in point. A national prevalence survey of people diagnosed with psychotic disorders revealed that less than 40 per cent of individuals with psychotic disorders reported receiving counselling or any form of psychotherapy over the previous year (Jablensky et al., 2000). Not surprisingly, this evidence provided a basis for cogent arguments for a redistribution in Australia of mental health resources for the treatment of psychosis towards psychosocial treatments and community supports (Neil et al., 2003). As also pointed out by Brian Martindale in the ISPS debate, there is compelling evidence that, despite the empirical support for their effectiveness (Pilling et al., 2002), family based interventions are rarely implemented into routine care (Fadden, 2006). From the perspective of the patient and carer, it has to be concluded that much of Zubin and Spring’s (1977) vision remains unfulfilled.

The history of the stress vulnerability frameworks: an integrative perspective on psychosis

During the twentieth century a range of theoretical orientations strongly influenced explanations of the development and course of psychosis, including psychoanalytic theory, family systems theory, learning theory, and a range of biological models (Perris, 1989). Elsewhere, these have been classified in terms of theories focusing on environmental factors, learning and development theories, and biological models. The problem, according to Zubin and Spring (1977), was that none of these met the criterion for an adequate aetiological explanation for the onset and course of schizophrenia (Zubin and Steinhauser, 1984). This was the starting point for their macrotheory or ‘heuristic framework’ for psychosis.

The original model offered the promise of providing an integrated aetiological account of schizophrenia which could break the empirical logjam attributed to the competing unifactorial explanations, and was promoted as a theoretical framework for integrating psychotherapeutic and biological treatments.

The popularity of the SVM can also, in our view, be understood as a reaction to the pessimism of the Kraepelinian disease concept of schizophrenia, which others have argued was underpinned by nineteenth century ideas of degeneration and disintegration with implicit assumptions of inevitable deterioration (Barrett, 1998a, 1998b). This pessimism was countered by a series of long-term follow-up studies conducted in the 1970s and 1980s, which highlighted the prevalence of an episodic course amongst the population diagnosed with schizophrenia—at odds with Kraepelin’s assumptions regarding prognosis. Although not entirely new, these data provided important grist for the SVM mill (Zubin et al., 1992).

The basic assumption of stress vulnerability models

The shared assumption of SVMs is that psychotic episodes result from an interaction between stable or distal factors (e.g., genetics or personality variables) and transient or proximal factors (e.g., life events, interpersonal conflict). The proponents of the stress vulnerability models agreed that interactions amongst these factors can result in acute psychotic psychopathology via the activation of latent vulnerability (Ciompi, 1989; Nuechterlein et al., 1992; Perris, 1989; Strauss et al., 1985; Zubin and Spring, 1977). Furthermore, as far as we know, all proponents subscribed to the notion that acute symptoms can be prevented or ameliorated by some combination of the individual’s personal resources, the emotional support of close others, and by biological treatments. However, further analysis reveals that a diversity of models emerged with varying fundamental assumptions. Some examples of these variations are outlined next, followed by a description of their evolution.

An overview: from ‘triggers’ to ‘integrated developmental perspectives’

According to Perris, the SVMs inherited older conceptualizations of individual vulnerability conveyed in the ancient Greek diathesis and in psychoanalytic accounts of the neuroses dating from the time of Freud (Perris, 1989). Perris also suggested that stress vulnerability proponents are indebted to Jaspers for linking hereditary predisposition (Anlage) and environment in his theory of the genesis of psychopathology (Jaspers, 1913, cited in Perris, 1989).

Paul Meehl’s (1962, 1989, 1992) theory of schizotaxia was perhaps one of the first aetiological arguments for an interaction between an underlying latent propensity for schizophrenia and environmental contingencies based upon empirical research. Citing findings on neurological soft signs, Meehl (1989) argued that schizotypes inherit an integrative defect of the central nervous system (CNS) which he labelled schizotaxia: ‘it is something wrong with every single nerve cell at all levels from the sacral cord to the frontal lobes’ (Meehl, 1989, p. 936). He conjectured that schizotaxia, with the addition of variable social reinforcement schedules, led to the development of schizotypal personality organization, characterized by anhedonia, cognitive slippage, ambivalence, and interpersonal alienation. Meehl hypothesized that approximately 10 per cent of so-called schizophrenes developed schizophrenia via a range of potentiators, including invalidating social relationships.

Zubin and Spring’s stress vulnerability model

The stress vulnerability nomenclature was introduced by Zubin and Spring (1977). They emphasized the episodic course of schizophrenia, as opposed to a continual disease process, arguing that individual episodes were triggered by endogenous and exogenous challenging events which exceeded the patient’s vulnerability threshold. Zubin and Spring conceptualized vulnerability as either a genetically or environmentally acquired level of risk for developing the disorder, which could be offset by coping capacities, and by an ability to learn from previous episodes.

Zubin and Steinhauser (1984) added the concept of etiotypes to the model, i.e., heterogeneous pathways leading to the development of schizophrenic vulnerability with equivalent behavioural and symptom outcomes. It was argued that aetiological life events could produce various etiotypes through genetic, biochemical, neurophysiological, developmental, or learning mechanisms. In other words, many pathways potentially led to vulnerability and ultimately psychosis. We would argue that these theorists foreshadowed the trauma-vulnerability pathway highlighted more recently by Read and colleagues in their traumatogenic model (Read et al., 2001).

These early versions of the SVM model were criticized on several fronts. The main concerns were that they failed to stipulate schizophrenia-specific aetiological pathways to vulnerability and that the conceptualization of stress within the model overlooked subjective appraisal of life events (Nicholson and Neufeld, 1992). Others criticized the model for its characterization of remission from positive symptoms as a state of equilibrium, because it failed to account for deterioration in other symptom domains, such as negative symptoms (Carpenter, 1981). For some, this formed the basis for a rejection of the SVM in favour of a synergetic account of the psychosocial ecosystem (Dauwalder and Hoffman, 1992).

The UCLA model

Nuechterlein and Dawson (1984) incorporated Zubin and Spring’s model into their heuristic conceptual framework. Drawing tentatively upon putative vulnerability factors, they attempted to outline the processes leading from stable, trait-like vulnerability to transient intermediate states (i.e., prodromal psychosis), and eventually to psychotic behaviours. They proposed that deficits in information processing were central to enduring vulnerability. They described interactions between these deficits and autonomic hyperactivity, and social competence and coping skills. When this interplay between enduring vulnerabilities became engaged in a vicious feedback loop with the social stressors and unsupportive social networks, transient intermediate states purportedly resulted. They argued that these states were marked by processing capacity overload, hyperarousal and deficient processing of socia...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• List of contributors
• Foreword
• Preface
• 1 Integration and the psychotherapies for schizophrenia and psychosis: where has the ‘new view’ of schizophrenia taken us?
• SECTION 1 Theoretical integration
• SECTION 2 Integration of psychotherapy: an international perspective
• SECTION 3 Integrating psychotherapeutic thinking and practice into ‘real world’ settings