Towards a theory of mental health professionals’ understandings of psychotic experiences

1. Towards a theory of mental health professionals’ understandings of psychotic experiences Dr. Clark Davison Highly Specialist Clinical Psychologist SPRIG, University of Sussex, 25th November 2011

2. Presentation and Discussion Background to the Project Who, What, When? Results and Implications Questions and Reflections What next?

3. Background to the Project • What was the project? • A qualitative grounded theory study conducted in 2008-2010. The research aimed to develop a localised theory of processes involved in developing understandings of psychotic experiences, based on the views of mental health professionals from an NHS Mental Health Trust in England. • Why research this? • Many theories of psychotic experiences in the existing professional domain e.g. Psychological, Sociological, Biological: • Different understandings have implications for professional practice and are of research interest. • Theories in the professional domain influence how individual practitioners’ understand and work with psychotic experiences, and the care clients receive from mental health services. • It is unclear how different theories to understanding psychotic experiences might facilitate or impede professionals in developing understandings of these, influence clinical practice, effect stigma, or how this compares to the influence of alternative approaches. • There is a need to explore how individual practitioners’ develop understandings and utilise theories in the professional domain.

4. Background to the Project Why research this? In addition to theories in the professional domain, the ways in which clients understand their psychotic experiences can influence individual practitioners’ developing understandings and interventions. The nature of this influence and the processes involved are unclear and also of research importance. National service guidance exists, reaching across professional disciplines and approaches, on how professionals should understand and treat psychotic experiences. This might also represent a significant influencing drive. Study Rationale Five potential influences on individual practitioners’ understandings of psychotic experiences in the current literature: psychological, sociological, and biological theories in the professional domain, client understandings, and service guidance. These provide the rationale and social utility of exploring professionals’ perspectives on developing understandings of psychotic experiences.

5. Who, What, When? • Study aims • The broad study aim was to develop some preliminary theory about the processes involved in how mental health professionals’ develop their understandings of psychotic experiences and how this impacts on elements of practice. This would include exploration into how professionals develop their personal understandings, perceive their own accounts to be different to that of others, and develop understandings of psychotic experiences with clients. • Method • 10 Mental Health Professionals interviewed from Sussex Partnership NHS Trust • Three broad question areas: 1. What are participants views and experiences of developing their personal understandings of psychotic experiences? 2. What are participants views of understandings that exist which differ from their own perspectives? 3. What are participants views and experiences of developing understandings of psychotic experiences with their clients?

6. Who, What, When? • Participants • 2 Psychiatrists, 1 Occupational Therapist, 4 Psychiatric Nurses, 2 Social Workers, 1 Clinical Psychologist. • Number of years working with psychotic experiences ranged from 2-35 years. • 5 participants worked in West Sussex Early Intervention in Psychosis Team, Five worked in St Leonard's Community Mental Health Team.

7. Results and Implications • Results • Two theoretical concepts emerged from the analytic process: 1.Taking a flexible approach to understanding and working with psychotic experiences, versus, taking a static approach and resisting changes to this approach, known as ‘flexibility-resistance to change’. 2.The location of power between different professionals, and client and professional in relation to explaining and intervening with psychotic experiences, known as: ‘the location of power’. • The theoretical concepts emerged from each of the three broad categories constructed: 1.Professionals’ personal understandings of psychotic experiences. 2.Facilitators of and constraints upon engaging clients in developing their understandings of psychotic experiences. 3.Developing shared understandings of psychotic experiences with clients.

8. Results and Implications

9. Results and Implications Theoretical Concept 1: Flexibility-Resistance to Change Flexibility and resistance to change emerged to represent two opposing ends on a spectrum. Each of the broad categories appeared to highlight how professionals and clients might occupy a more ‘flexible’ or ‘resistant to change’ position either in understanding psychotic experiences, their ability to engage in a process of developing understandings, or their approach to developing understandings. Participants also highlighted how people might move along the spectrum. Theoretical Concept 2: The Location of Power The location of power emerged to conceptualise how each of the broad categories appeared to highlight how professionals and clients could hold different degrees of power in relation to each other. The term ‘power’ related to explanations of and interventions for psychotic experiences. If a person held what was regarded to be a more valued or legitimate explanation, they were deemed to hold more explanatory power perhaps in comparison to another person with a less valued explanation. Thus power differentials between client and professional or professional and professional could be unbalanced. If a difference of opinion existed on the intervention to be taken, the person whose choice was followed was regarded to hold more power in this respect.

10. Results and Implications Broad Category 1: Professionals’ Personal Understandings of Psychotic Experiences …you look at things in a systemic way […] there must be various factors in terms of ideology. A multi-factorial model is what I’m saying… (Fin)

11. Results and Implications

12. Results and Implications Broad Category 2: Facilitators of and Constraints upon Engaging Clients in Developing their Understandings of Psychotic Experiences …there are other people with whom we can work in a collaborative way and change medication when we need to and so on […] we also get people who are quite stuck in their thinking […] That makes a big difference into how well you can work with people. (Adam)

13. Results and Implications

14. Results and Implications Broad Category 3: Developing Shared Understandings of Psychotic Experiences with Clients …please respect my views, I’ll respect yours. (Emily)

15. Results and Implications

16. Results and Implications

17. Results and Implications And so... The three broad categories appeared to represent three different stages in the process of a professional developing a shared understanding of psychotic experiences with a client. The two theoretical concepts represented elements that could facilitate or constrain this process. In this way the study moved towards developing a middle-range theory of the processes involved in professionals developing understandings of psychotic experiences. It should be noted professionals did not appear to be necessarily ‘flexible’ or ‘resistant to change’, aiming to ‘share’ or ‘retain’ power’, but instead there was a dimensional aspect to the bipolar constructs. Professionals could move along a ‘spectrum’ of flexibility-resistance to change and location of power, sometimes holding more or less flexibility or desire to share power. The theoretical model that developed in this study indicates when professionals hold more flexible personal understandings and approaches to working with people with psychotic experiences, and aim to share power over the intervention and explanatory model; there is greater potential for client and professional developing a shared understanding of psychotic experiences. When professionals hold more resistant to change understandings and approaches, aiming to retain power; clients are less likely to develop their understandings.

18. Results and Implications Clinical Implications The theory developed indicated if professionals occupy a more flexible position towards their understanding of and approach to working with psychotic experiences, this may aid professionals in working with each other, increase the likelihood of professional and client engagement, and facilitate the development of a shared understanding of psychotic experiences with their clients. Perhaps the move towards adopting more flexible positions is reflected within the updated NICE (2009) guidelines on schizophrenia. These go some way towards clarifying standards for mental health professionals’ work with psychotic experiences. The guidelines indicate a move away from using medication as the only treatment option and towards recognising the value of exploring clients’ psychotic experiences. They advocate gaining client’s perspectives on intervention, considering these perspectives when developing treatment plans, and offering clients choice around available treatments, as part of routine clinical practice.

19. Reflections and Questions

20. What Next? • Publication • Aiming to publish several articles in peer reviewed journals • Future Research • Qualitative research into professionals’ understandings of and work with psychotic experiences is at a relatively early stage. More research is needed to clarify and develop the findings of this study and their application to other contexts. • Future research might explore: • How professional understandings impact on clinical work. • Use of quantitative research methods on a larger scale to evaluate positions of flexibility and resistance or the location of power more fully and their impact on therapeutic outcomes. • Resistance to change and how this might be overcome.