The Intersubjective Arena of the Psychotherapy for Psychosis

315 Pages·2016·7.06 MB·English

The Intersubjective Arena of the
Psychotherapy for Psychosis:
A Phenomenological Account of
Therapists’ Experiences

Andreas Vassiliou, BSc (Hons)

A thesis submitted for the degree of Doctorate in
Counselling Psychology and Existential
Psychotherapy

Department of Psychology
Middlesex University
2016
ACKNOWLEDGEMENTS

I would like to thank my family and partner for their support and encouragement
when writing this thesis. Thank you for believing in me and for your support
throughout this long journey. I want to thank my primary and secondary supervisors
for their support and encouragement, advice and guidance throughout the research
process. All my close friends deserve a mention here, not only for their support and
encouragement, but also for their understanding when I was not available while being
engaged with this endeavour. Moreover, I would like to thank all the people who have
participated in this research project. Thank you for your openness, honesty, courage
and cooperativeness. Without you this research would have been impossible; I really
hope I have done justice to your narratives. Last, but certainly not least, I would like
to thank from the depths of my heart all the people whom I have met and worked with
while working in inpatient psychiatric ward settings. Thank you for being open and
playfully engaged in our dialogues and the exceptional betweenness you allowed me
to experience. Thank you for allowing me the opportunity to navigate between the
Heraclitian idios kosmos and koinos kosmos and for being able to contain my terror in
that betweenness.

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STATEMENT OF AUTHORSHIP

This dissertation was written by Andreas Vassiliou and has ethical clearance from the
New School of Psychotherapy and Counselling and the Psychology Department of
Middlesex University. It is submitted in partial fulfilment of the requirements of the
New School of Psychotherapy and Counselling and the Psychology Department of
Middlesex University for the Degree of Doctor of Existential Counselling
Psychology. I confirm that this is an original piece of work and has not previously
been submitted and approved for the award of a degree by this or any other University
within or outside the United Kingdom. This thesis is, therefore, the product of my
personal investigations and any material and information that have been employed
that is not my own have been appropriately identified by providing references which
are appended.

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ABSTRACT

New exciting literature that points to the significance of considering intersubjective
processes in therapeutic work with people diagnosed with psychosis has been recently
developed in the realms of phenomenological psychology and psychiatry. However,
the research literature reveals an emphasis towards the exploration of clients’
processes and an underestimated inclination towards the in-depth exploration of
therapists’ experiences that work from an intersubjective/interrelational perspective
with this client group. Given this particular limitation, we therefore need a more
detailed exploration of what this work is like, and how therapists make sense of this
work considering this intersubjective turn. This project has therefore attempted to
shed light on the intersubjective processes of psychotherapy for psychosis from the
therapists’ point of view while emphasising how the therapeutic praxis can be
grounded upon firm existential-phenomenological principles. The study explored the
subjective experiences of six counselling psychologists and/or therapists who
identified themselves as working intersubjectively with psychosis. After careful
consideration, Interpretative Phenomenological Analysis (IPA) was employed as the
most suitable methodology in order to explore the interviews and to gain insight into
participants’ lived experiences of their relationships with clients. The analysis of data
revealed four key themes: the primacy of sense-making, a relational approach to
therapy, therapists’ processes in the rupture of relatedness and the lived experience of
being-with. Despite the congruence with the limited literature on therapists’ lived
experiences of their intersubjective work with psychosis, the results of this study also
shed light on some neglected areas of consideration with regards to the therapeutic
process, while encouraging the consideration of existential/phenomenological
contributions towards both the understanding and clinical praxis of the psychotherapy
for psychosis. This piece of work consists therefore of a significant contribution to the
limited literature on phenomenological and intersubjective work with psychosis and is
an essential addition to counselling psychology literature.

Keywords: Psychosis, Intersubjectivity, Counselling Psychology, Psychotherapy

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TABLE OF CONTENTS

ABBREVIATIONS .................................................................................................................................. 8
TRANSCRIPT NOTATIONS ................................................................................................................ 8
TERMINOLOGY .................................................................................................................................... 9
PREFACE .............................................................................................................................................. 11
NOTE ON WRITTING STYLE ......................................................................................................... 11
INTRODUCING THE AUTHOR ...................................................................................................... 12
INTRODUCING THE RESEARCH PROJECT ................................................................................ 16
SITUATING THE AUTHOR WITHIN THE PROJECT .................................................................. 17
EXPLANATION OF MAIN CONCEPTS ......................................................................................... 19
SYNOPSIS ......................................................................................................................................... 21
CHAPTER 1: INTRODUCTION ........................................................................................................ 23
1.1 AIMS OF THE RESEARCH PROJECT ...................................................................................... 23
1.2 EPISTEMOLOGICAL POSITION .............................................................................................. 23
1.3 SUMMARY OF CONTENTS ...................................................................................................... 24
CHAPTER 2: LITERATURE REVIEW ............................................................................................ 26
2.1 INTRODUCTION ........................................................................................................................ 26
2.2 PSYCHOSIS ................................................................................................................................. 26
2.2.1 Approaching psychosis phenomenologically ....................................................................... 26
2.2.2 Early existential-phenomenological approaches to psychosis .............................................. 30
2.2.3 Contemporary phenomenological approaches ...................................................................... 36
2.2.4 A critical review of contemporary phenomenological approaches ....................................... 43
2.3 A PHENOMENOLOGICAL APPROACH TO INTERSUBJECTIVITY ................................... 46
2.3.1 Overview ............................................................................................................................... 46
2.3.2 A critical review of Heidegger, Sartre and Husserl .............................................................. 49
2.3.3 The consideration of Merleau-Ponty, Binswanger, Buber and Scheler ................................ 51
2.3.4 Synopsis and implications ..................................................................................................... 57
2.4 PSYCHOTHERAPY FOR PSYCHOSIS ..................................................................................... 62
2.4.1 A brief history of the psychotherapy for psychosis .............................................................. 62
2.4.2 Therapists’ experiences ......................................................................................................... 64
2.4.3 Intersubjectivity informed psychotherapy for psychosis ...................................................... 71
2.5 RATIONALE OF THE RESEARCH PROJECT ......................................................................... 74
2.5.1 Research focus ...................................................................................................................... 74
2.5.2 Relevance to counselling psychology and psychotherapy .................................................... 75
2.5.3 A reflexive account ............................................................................................................... 76

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CHAPTER 3: METHODOLOGY ....................................................................................................... 78
3.1 INTRODUCTION ........................................................................................................................ 78
3.2 THE BASIS FOR ADOPTING A QUALITATIVE METHODOLOGY .................................... 79
3.3 EMBRACING THE PHENOMENOLOGICAL METHOD ........................................................ 83
3.3.1 A synopsis of phenomenology .............................................................................................. 84
3.3.2 The choice of Interpretative Phenomenological Analysis (IPA) .......................................... 86
3.3.3 The consideration of alternative methodologies ................................................................... 89
3.3.4 Philosophical and theoretical underpinnings of IPA ............................................................ 93
3.3.5 A critical appraisal of IPA .................................................................................................... 94
3.4 ENSURING QUALITY AND RIGOUR ..................................................................................... 97
3.5 THE PRIMACY OF REFLEXIVITY .......................................................................................... 98
CHAPTER 4: METHODS .................................................................................................................. 100
4.1 SAMPLING, RECRUITMENT AND DEMOGRAPHICS ....................................................... 100
4.1.1 Sampling ............................................................................................................................. 100
4.1.2 Inclusion criteria ................................................................................................................. 101
4.1.3 Recruitment ......................................................................................................................... 101
4.1.4 Demographics ..................................................................................................................... 103
4.2 ETHICAL CONSIDERATIONS ................................................................................................ 105
4.2.1 Anonymity and confidentiality ........................................................................................... 106
4.2.2 Informed Consent ................................................................................................................ 106
4.2.3 Debriefing ........................................................................................................................... 107
4.3 DATA COLLECTION ............................................................................................................... 107
4.3.1 Videoconference as a tool for qualitative research ............................................................. 107
4.3.2 Construction of questionnaire, interviewing schedule and progress .................................. 110
4.4 DATA ANALYSIS .................................................................................................................... 112
4.4.1 Transcription ....................................................................................................................... 113
4.4.2 The steps of data analysis ................................................................................................... 114
4.5 REFLEXIVITY, BRACKETING AND PERSONAL BIAS ..................................................... 116
CHAPTER 5: RESULTS .................................................................................................................... 121
5.1 OVERVIEW ............................................................................................................................... 121
5.2 MAJOR THEMES AND SUBTHEMES ................................................................................... 123
5.2.1 Major theme 1: The primacy of sense-making ................................................................... 123
5.2.1.1 Subtheme 1: Focusing on meaningfulness and comprehensibility ............................. 124
5.2.1.2 Subtheme 2: The impact of lived experiences on distress and psychosis ................... 126
5.2.1.3 Subtheme 3: Looking at self-processes ....................................................................... 129
5.2.1.4 Subtheme 4: Understanding informed by how therapist is affected ........................... 131
5.2.2 Major theme 2: A relational approach to therapy ............................................................... 133
5.2.2.1 Subtheme 1: Prioritising and mapping relationships .................................................. 134
5.2.2.2 Subtheme 2: The use of first and second person perspectives .................................... 136

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5.2.2.3 Subtheme 3: The flexibility of boundaries .................................................................. 139
5.2.3 Major theme 3: Therapist’s processes in the rupture of relatedness ................................... 143
5.2.3.1 Subtheme 1: Sense of autonomy threatened ............................................................... 143
5.2.3.2 Subtheme 2: Disruption of reflective capacities and contradictions ........................... 148
5.2.3.3 Subtheme 3: Assuming responsibility ......................................................................... 151
5.2.3.4 Subtheme 4: Compensatory mechanisms .................................................................... 153
5.2.4 Major theme 4: The lived experience of being-with ........................................................... 157
5.2.4.1 Subtheme 1: Relatedness and connectivity ................................................................. 158
5.2.4.2 Subtheme 2: Therapist’s self-experience .................................................................... 163
5.2.4.3 Subtheme 3: Oscillations between distance and proximity ......................................... 167
5.2.4.4 Subtheme 4: Bestowing meaning ................................................................................ 172
5.3 SYNOPSIS ................................................................................................................................. 175
CHAPTER 6: DISCUSSION .............................................................................................................. 177
6.1 INTRODUCTION ...................................................................................................................... 177
6.2 DISCUSSING THE MAIN THEMES ....................................................................................... 177
6.2.1 The primacy of sense-making ............................................................................................. 177
6.2.2 A relational approach to therapy ......................................................................................... 186
6.2.3 Ruptures in relatedness and the lived experience of being-with ......................................... 192
6.3 IMPLICATIONS FOR COUNSELLING PSYCHOLOGY ...................................................... 202
6.3.1 Implications for practice ..................................................................................................... 202
6.3.2 Implications for supervision and training ........................................................................... 206
6.4 METHODOLOGICAL CONSIDERATIONS AND LIMITATIONS ....................................... 207
6.5 SUGGESTIONS FOR FURTHER RESEARCH ....................................................................... 212
6.6 PERSONAL REFLEXIVITY ..................................................................................................... 214
CHAPTER 7: CONCLUSION ........................................................................................................... 216
REFERENCES .................................................................................................................................... 218
APPENDICES ...................................................................................................................................... 247
Appendix I: Project’s Ethical Approval ........................................................................................... 248
Appendix II: Project’s Advertisment ................................................................................................ 249
Appendix III: Participant Information Sheet .................................................................................... 250
Appendix IV: Background Information Sheet .................................................................................. 256
Appendix V: Informed Consent Form .............................................................................................. 258
Appendix VI: Debriefing Form ........................................................................................................ 259
Appendix VII: Interview Schedule ................................................................................................... 260
Appendix VIII: Paula’s original transcript ....................................................................................... 261
Appendix IX: IPA full transcript analysis for Paula ......................................................................... 268
Appendix X: Themes and subthemes with excerpts for entire sample ............................................. 286

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ABBREVIATIONS

BPS: British Psychological Society
CoP: Counselling Psychology
CoPt Counselling Psychologist
E-P: Existential-Phenomenological
APA: American Psychiatric Association
IPA: Interpretative Phenomenological Analysis
DSM: The Diagnostic and Statistical Manual of Mental Disorders
ICD: The International Classification of Diseases
NHS: National Health Service
CBT: Cognitive Behavioural Therapy

TRANSCRIPT NOTATIONS

(P): Significant pause
(p): Brief pause
....: Real name (person, organization, setting, etc.) omitted to safeguard
anonymity
__: Information omitted to safeguard confidentiality

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TERMINOLOGY

It should be noted that all terminology employed will be as thoroughly defined as
possible and presented within the epistemological and ontological frameworks within
which the study was conducted. I am aware that some readers may not feel
comfortable with the employment of the term ‘psychosis’ and the phrases
individual(s) diagnosed with psychosis or person(s) with psychosis will be employed
in this research paper in an effort to avoid using terms like psychotic or schizophrenic
which are considered to stigmatise individuals (e.g. Haghighat, 2008; Dinos et. al,
2004; Keusch, Wilentz, & Kleinman, 2006). Words or phrases within single quotation
marks that are presented throughout the research will be employed to indicate
constructed ideas, notions and concepts, or conditions that have been considered
according to their context of interest (e.g. medical and psychiatric settings), with the
intention of bringing taken for granted concepts into an open enquiry for the reader.
Moreover, it should be noted that when I am referring to discourse/s, I refer to
patterns or regularities routed in language or written form, therefore, the ways in
which we think about particular phenomena (e.g. Bakhtin, 1981).

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“Εάν µη έλπηται
ανέλπιστον ουκ εξευρήσει,
ανεξερεύνητον εόν και άπορον”

(Ηράκλειτος)

“If you don't bear hope
you will not discover the unforeseen
by rendering it unexplored and beyond reach”

(Heraclitus)

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