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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
Presentation and Discussion
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Background to the Project
Who, What, When?
Results and Implications
Questions and Reflections
What next?
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:
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Different understandings have implications for professional practice and are of
research interest.
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Theories in the professional domain influence how individual practitioners’
understand and work with psychotic experiences, and the care clients receive
from mental health services.
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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.
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There is a need to explore how individual practitioners’ develop
understandings and utilise theories in the professional domain.
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.
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
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10 Mental Health Professionals interviewed from Sussex Partnership
NHS Trust
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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?
Who, What, When?
Participants
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2 Psychiatrists, 1 Occupational Therapist, 4 Psychiatric Nurses, 2 Social
Workers, 1 Clinical Psychologist.
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Number of years working with psychotic experiences ranged from 2-35
years.
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5 participants worked in West Sussex Early Intervention in Psychosis
Team, Five worked in St Leonard's Community Mental Health Team.
Results and Implications
Results
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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’.
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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.
Results and Implications
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.
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)
Results and Implications
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)
Results and Implications
Results and Implications
Broad Category 3: Developing Shared Understandings of Psychotic
Experiences with Clients
…please respect my views, I’ll respect yours. (Emily)
Results and Implications
Results and Implications
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.
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.
Reflections and Questions
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:
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How professional understandings impact on clinical work.
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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.
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Resistance to change and how this might be overcome.