Building bridges to observational perspectives: A grounded theory of therapy processes in psychosis

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Building bridges to observational perspectives:A grounded theory of therapy processesin psychosis

Sarah Dilks1*, Fiona Tasker2 and Bernadette Wren31South London and Maudsley NHS Foundation Trust, North CMHT, London, UK2Birkbeck College, University of London, London, UK3The Tavistock Clinic, London, UK

Objectives. This study set out to explore therapy processes in psychosis with aninitial focus on reflexivity and how this might be expressed in therapy conversations.

Design. Leiman’s (2000) definition of reflexivity was used as a starting-point for anexploratory investigation of the use of language as reflective activity. Grounded theorywas chosen as an appropriate methodology to distil an explanatory account across thequalitative data collected.

Method. Six psychologist-client pairs supplied three tapes of therapy sessions spreadout across the course of therapy. Each participant was separately interviewed on twooccasions to ascertain their views of therapy and of the emerging grounded theory.

Results. A grounded theory was developed conceptualizing the processes andactivities in psychological therapy in psychosis.

Conclusions. ‘Building bridges to observational perspectives’ summarizes the coreprocess in psychological therapy in psychosis. Therapy in psychosis is understood asintimately ‘linking the social and internal world’ in a dialogical process aimed atenhancing the client’s ‘functioning in the social world’ rather than at specificallydeveloping the private mental experience of reflexivity or mentalizing.

This study was prompted by an interest in the therapy processes in psychosis that might

contribute to the subjective awareness and explicit articulation of private mental

experience (activity that can broadly be labelled reflexivity). The first author’sexperience as a UK clinical psychologist working with people experiencing psychosis

had suggested the potential importance of the therapist suggesting possible labels and

meanings for subjective experience; thereby making this experience explicit and

allowing it to be manipulated by the person (kept or changed). As described in more

detail below, it seemed this activity could be understood in different terms from

* Correspondence should be addressed to Dr Sarah Dilks, South London and Maudsley NHS Foundation Trust, North CMHT,37 Tamworth Road, London CR0 1XT, UK (e-mail: [email protected]).

TheBritishPsychologicalSociety

209

Psychology and Psychotherapy: Theory, Research and Practice (2008), 81, 209–229

q 2008 The British Psychological Society

www.bpsjournals.co.uk

DOI:10.1348/147608308X288780


different theoretical and therapeutic models and might therefore be regarded as a

common process in therapy. Combined with a consideration of the literature on therapy

process research and that relating to what we are calling reflexivity, this interest led to

the choice of a dialogical definition of reflexivity to focus a qualitative exploration of

therapy processes in psychosis. It is pertinent at this point to note that we follow

current practice in UK clinical psychology in referring to psychosis and psychoticexperiences rather than using psychiatric diagnostic categories like schizophrenia

(Bentall, 2003). This is based on concern about the validity of psychiatric diagnostic

systems (as discussed by Bentall, 2003; Boyle, 2002).

Process research in psychotherapy generally and in relationto psychotherapy with psychosisReviews of psychotherapy process research, such as those by Llewelyn and Hardy

(2001), Roth and Fonagy (1996), Sachse and Elliott (2001), and Stiles, Honos-Webb, and

Knobloch (1999), conclude that reliable process–outcome links between various

therapist, client, and therapy-specific factors have been hard to find. Although some

robust links have been identified in hypothesis-testing studies (particularly between

good therapeutic alliance and outcome), what emerges generally is a picture of

complexity. However, such reviews also suggest that common processes (such asa positive therapeutic alliance or emotional regulation) operating across therapy

modalities might be important in outcome. Stiles, Honos-Webb, and Surko (1998)

therefore suggest using qualitative and narrative analyses specifying processes at the

level of the client–therapist pair to take forward psychotherapy research.

With the exception of Lysaker and colleagues’ work on the role of narrative in

recovery from psychosis (e.g. Lysaker, Lancaster, & Lysaker, 2003; Lysaker & Lysaker,

2002; Lysaker et al., 2006), recent studies of therapy in psychosis have not

systematically set out to develop more abstract explanatory models of therapyprocesses, concentrating instead on particular examples of therapy from the standpoint

of existing therapeutic models (e.g. Grazebrook et al., 2004; Lombardi, 2003).

In comparison with therapy in other forms of distress then, therapy processes in

psychosis are relatively unexamined. It is therefore currently unclear whether findings

suggestive of the operation of common processes in psychotherapy across different

therapy modalities might also apply to therapy in psychosis.

Concepts relating to the awareness and articulation of private mental experienceThere are a variety of concepts that might inform our understanding of the subjective

awareness and explicit articulation of private mental experience (what we are callingreflexivity). These include: metacognition (e.g. Morrison, 2001; Teasdale, 1999);

mentalizing (e.g. Langdon, Coltheart, Ward, & Catts, 2001); theory of mind (Frith,

1994); reflective function (Fonagy, Gergely, Jurist, & Target, 2004; Fonagy, Target,

Steele, & Steele, 1998); and ideas arising from a narrative or dialogical perspective

(e.g. Stiles, 1999).

Metacognition, mentalizing, theory of mind, and reflective functionAt the broadest level, thinking about (assumed) mental processes, such as thoughts andfeelings, is referred to as metacognition (Morrison, 2001; Teasdale, 1999). Mentalizing

more specifically refers to the ‘cognitive capacity to infer causal mental states in order to

210 Sarah Dilks et al.


explain and predict consequent thoughts and behaviour and, more generally, people’s

capacity to reflect upon the unique subjective lives of both themselves and other

people’ (Langdon et al., 2001, p. 82). In using the term mentalizing interchangeably

with their concept of reflective function in an attachment theory context, Fonagy

and colleagues (Fonagy & Target, 1997; Fonagy, Target, Steele, & Steele, 1998)

specifically emphasize the developmental, interpersonal context of the origins ofmentalizing, and its critical place in self-organization.

Theory of mind is defined as the ability to interpret the speech and action of others

based on inferring the other person’s point of view as a being with a separate mind

(Frith, 1994). Investigations of theory of mind and mentalizing in psychosis based,

respectively, on Frith (1979, 1994, 1997) and Hemsley’s (1998, 2005) work seem to

imply a deficit model (Boyle, 2002) where people diagnosed with schizophrenia (sic)

are understood as lacking theory of mind or mentalizing capacity (Brune, 2005).

However, the experimental tests of these models suggest that what we are callingreflexivity can be mobilized at some times and not at others by those experiencing

psychosis (Bentall, 2003; Drury, Robinson, & Birchwood, 1998; Sarfati, Passerieux,

& Hardy-Bayle, 2000), leaving open the question of what might influence the operation

of reflexivity for these individuals.

Narrative and dialogical approachesNarrative and dialogical approaches share a common emphasis on the conversational

process of therapy and the importance of the construction of meaning in affecting

the experience of distress (Georgaca, 2001; Hermans, 1996; Leiman, 1997, 2000;

Stiles, 1999; White, 1987, 1995; White & Epston, 1990). From the standpoint of these

approaches, reflexivity would seem to be understood as taking an observing position in

relation to experience through the interaction between different self-positions or voices.

Dialogical approaches specifically regard self-hood as multi-voiced rather than

unitary, seeing the experience of self as continually constructed through dialogue inthe internal and external world. In applying this understanding to psychotherapy,

Stiles (1999) makes the point that different psychotherapy theories have in common

the idea that clients bring a range of perspectives to therapy, though these may

be conceptualized differently, for instance, as schemas in CBT, internal objects in

psychoanalytic psychotherapy, or voices in narrative therapy. Like Georgaca (2001) and

Hermans (1996; Hermans, Rijks, & Kempen, 1993), he suggests that the aim of therapy is

to decrease the rigidity in the range of internal voices (or, by implication, schemas,

internal objects, etc.) used by clients and to increase the interplay between differentpositions or voices. Stiles (1999, p. 3) and Brinegar, Salvi, Stiles, and Greenberg (2006,

p. 165) refer to creating symbolic ‘meaning bridges’ between different voices in both

internal, private conversations, and external conversations with a therapist in order to

achieve this.

Lysaker and colleagues (Lysaker & Buck, 2006; Lysaker & Daroyanni, 2006; Lysaker

& Lysaker, 2002; Lysaker, Lysaker, & Lysaker, 2001) have specifically focused on concep-

tualizing psychotherapy in psychosis from the standpoint of narrative approaches.

Lysaker and Lysaker (2001) suggest that changes in a subjective sense of self in psychosisare related to the collapse of a dialogically based self and that recovery might be

facilitated by its restoration. In their review of this emerging field, France and Uhlin

(2006) suggest that change in narrative content and form may therefore offer a useful

way of assessing outcome in psychosis. Lysaker and colleagues have indeed developed

Building bridges 211


the Scale to Assess Narrative Development (Lysaker, Wickett, Campbell, & Buck, 2003;

Lysaker et al., 2006) with this aim. However, there are methodological and conceptual

problems in taking a quantitative approach to examining narrative, as represented for

instance by the STAND and by Fonagy et al.’s measure of reflective function/mentalizing

derived from the adult attachment interview (a measure of the quality of early

attachment experiences: Fonagy et al., 1998; George, Kaplan, & Main, 1996). Ratings ofnarrative complexity and coherence are judgements based on an interaction between

speaker and listener (c.f. Harper, 2004); complexity and coherence do not ‘exist’

independently in narrative content. So, while Lysaker and colleagues’ work has some

shared conceptual interests with our study we took an exploratory position regarding

the specific role of narrative in therapy in psychosis rather than seeking to build on

their work.

It appeared then from reviewing existing concepts potentially mapping on to

reflexivity that there is a way of relating to subjective experience (objectifying it inlanguage), the use of which varies, that can be identified in different activities (adult

attachment interviews, therapy narratives, and theory of mind experimental tasks).

Examining these activities involves different assumptions about the origins of reflexivity,

its mutability, and its relationship to the idea of an objective reality. We were not

attempting to account for the origins of reflexivity, as does for example attachment theory

(Fonagy et al., 2004) or theory of mind (Frith, 1979, 1994, 1997). Rather, we were

interested in determining how reflexivity might be identified in therapy in psychosis

through the use of language and how the therapist might facilitate this activity.

Focusing the studyLeiman’s (2000) definition of reflexivity was used as a specific starting-point for this

study. It was chosen because it focuses on the public demonstration, through language

use, of an active and ongoing relationship to subjective experience and because it

implies that this objectifying of experience can change through relationships withothers (including presumably a therapist).

To reflect requires the ability to create and use signs that refer to one’s own activity,

whether external or internal. To be the ‘author of ones’ thoughts and feelings’ means that

the person is able to establish an internal subject-object relation (i.e. he or she can objectify

personal experience and mental processes, and use some semiotic means to make sense of

those complex phenomena as objects of reflective actions). To objectify one’s own actions,

experiences, thoughts and feelings is an advanced task developed through a number of

transformative stages and modes of ‘joint subjectness’ (Leiman, 2000, pp. 391–392).

Narrative and dialogical approaches, including Leiman’s, draw on the work of Vygotsky

(1978) in adopting a view of therapy as a shared process negotiated between therapist

and client. Vygotsky (1978) proposed that development is essentially a social process

progressed through the scaffolding of activities by another person, and that individuals

have a zone of proximal development representing the new capabilities enabled for an

individual by that joint enterprise. Centrally, Vygotsky (1978) saw language as a tool

used to influence the social world (Wertsch, 1991), but also as a tool with an intra-

personal function; ‘social speech’ (p. 27) turned inwards to direct one’s own activity in‘inner speech’ (p. 27).

However, while Leiman’s definition of reflexivity focuses on the use of language in

objectifying experience, it does not suggest how to operationalize this use. For this

reason, grounded theory was chosen as an appropriate qualitative methodology to allow



both exploration of this area and further conceptual development (Charmaz, 2003;

Glaser, 1978; Glaser & Strauss, 1967; Henwood & Pidgeon, 2003; Strauss & Corbin,

1998). We adopted a critical realist position (Annells, 1996; Guba & Lincoln, 1998;

Willig, 2001) in relation to ideas about the nature of reality, the means of obtaining

knowledge about the individual and the particular application of grounded theory.

Consistent with this position, it is recognized that the first author brings particularfamiliarity to working with those experiencing psychosis and that the focus of the study

on reflexivity was prompted by this experience and by an awareness of the related

literature. We take Henwood and Pidgeon’s (2003) view that existing literature can both

serve as a starting-point in sensitizing the researcher to the area of inquiry, and aid in the

later stages of conceptual development.

In summary, the starting-point for this exploration of processes in psychological

therapy in psychosis was a focus on reflexivity and how this might be expressed in

therapy conversation. The initial research questions were: (i) how might reflexivity beexpressed in the way people experiencing psychosis talk about subjective experience?

(ii) what are the commonalities and divergences in this process across individuals?

(iii) how do people experiencing psychosis talk about their subjective experiences at

different points in the therapy process? and (iv) how might the therapist facilitate

reflexivity?

DesignThe initial dataset consisted of three taped therapy sessions, spaced out over time,

collected from each of six therapist–client pairs. This was supplemented by semi-

structured interviews with each of the participants. In the Time 1 (T1) interviews the

psychologists and clients were each separately asked about their experience of therapy.

Subsequently, in the later Time 2 (T2) interviews the same participants were separatelyasked about their views of the model of therapy emerging from the grounded theory

analysis of therapy tapes and T1 interviews.

Method

ParticipantsApproaches were made to clinical psychologists identified as working in the NHS withpeople experiencing psychosis through their membership of the British Psychological

Society’s Special Interest Group in Psychosocial Rehabilitation or through the first

author’s knowledge of who was working in this field. Participant information was

sent sequentially to psychologists as they came forward and they were included in the

study if they were subsequently able to identify a client participant from their caseload.

There were no exclusion criteria for participants though psychologists were asked

to identify clients who had been given diagnostic labels associated with obtaining

NHS psychological therapy for experiences identified as psychotic (schizophrenia andschizoaffective disorder). Participants were not otherwise selected according to specific

characteristics, e.g. ethnicity or gender, following Glaser’s (1992) position that the

relevance of particular factors needs to emerge from the analysis rather than being

assumed in advance. Participant details are given in Table 1.

ProcedureInitial data sampling involved the analysis of transcribed audiotapes of individual

psychological therapy sessions with people experiencing psychosis. No criteria for



Table

1.Therapistandclientcharacteristicsofinitialsample

Psychologist

(nam

echanged)

Gender

Age

Ethnicity(self-identified)

Therapeuticorientation

Yearsqualified

Mark

M37

White

Integrativea

5Lee

F30

Mixed

Integrative

2Charlotte

F37

WhiteBritish

CBT

9Sue

F33

WhiteBritish

Integrative

2Lo

uise

F37

WhiteBritish

CBT

10

Liz

F46

WhiteBritish

Integrative

9

Client(nam

echanged)

Gender

Age

Ethnicity(self-identified)

Diagnosisb

Yearsin

contact

withservices

Colin

M33

WhiteBritish

Schizophrenia

25

Anna

F36

Black

African

Schizophrenia

5Andrew

M35

WhiteBritish

Depressionwithpsychoticepisodes

c3

Isabel

F34

WhiteEuropean

Schizoaffectivedisorder

14

Juliet

F37

Nigerian

Schizoaffectivedisorder

5Tanya

F36

Black

British

Schizophrenia

18

aTheterm

‘integrative’refersto

thespecifyingofm

ultiplemodelsusedto

inform

therapy.Those

nam

edbytherapistsincluded

cognitivebehaviouraltherapy(C

BT),

psychoanalyticapproaches,andsystem

icapproaches.

bDiagnosesreferto

theDSM

IVpsychiatricclassificationsystem

(American

PsychiatricAssociation,1994).

cAndrewwas

included

withtheinitialsam

pledueto

concernsabouttheappropriatenessofusingpsychiatricdiagnosesto

distinguishbetweenclients’experiences

(see

Bentall,

2003;Boyle,

2002,foradiscussion),andbecause

theanalysisofthetherapytapes

suggestedtheactivities

ofAndrew

andCharlottewerenot

qualitativelydifferentto

therest

ofthesample.



model or length of therapy were specified for this investigation. Six psychologist–client

pairs were recruited; each pair supplied three therapy tapes, spaced out across the

course of their therapy to allow consideration of the process of psychological therapy in

psychosis. This produced a total of 19 therapy tapes (one pair supplied an extra tape due

to poor sound quality) supplied over a period of 11 months. Specific therapy sessions

are indicated in the results by giving the (anonymized) therapist’s name followed bythe client’s, with the number of the therapy tape supplied, e.g. ‘Lee/Anna-2’ refers to

psychologist Lee talking with client Anna in the second therapy tape they supplied.

In addition, each psychologist and client was also interviewed separately by the first

author about their views on the process of therapy using a semi-structured interview.

The T1 interviews took place after all three therapy session tapes had been collected

from each pair. A second (T2) semi-structured interview was also conducted separately

with each of the psychologists and clients to ascertain their views on the emerging

model as it was developed over the course of the analysis. Twelve T1 interviews werecollected from each of the six psychologist and clients, and eleven T2 interviews were

also collected (1 client declined to be interviewed a second time). Copies of the

interview guidelines are available on request from the first author.

Successful applications for NHS research ethics scrutiny were made to a multi-centre

research ethics committee, as well as to individual NHS ethics and research and

development committees for each psychologist/client pair participating from different

health authority areas and NHS trusts. Steps were taken to ensure informed consent, to

preserve the anonymity of participants, and to ensure the confidentiality of tapedmaterial.

Grounded theory analysisGrounded theory involves an iterative process of moving backwards and forwards

between coding and conceptualizing data. Chamberlain (1999), Charmaz (1994, 1995),

Henwood and Pidgeon (2003), and Willig (2001) all give overviews of procedures in

grounded theory from open to focused coding, the use of research memos, and

theoretical sampling. The analysis in this study drew particularly on descriptions of the

grounded theory method given by Charmaz (1994, 1995), Glaser (1978), and Strauss andCorbin (1990, 1998).

Data for the study were gathered and analysed by the first author. Ensuring the

quality of the study included careful documentation in memos of the development of

codes and categories to ensure that these emerged from the data and this was audited

via the supervision process. Checks on the emerging grounded theory were also

provided by accessing multiple perspectives on the phenomena under investigation

including: examining therapy sessions; interviewing psychologists and clients; and

through the theoretical sampling (c.f. Glaser, 1978; Strauss & Corbin, 1998) of additionaldata (not reported here).

Results

The central therapy process identified through this analysis is presented first as thebasis for the rest of the results section. It is presented in its final form for the sake of

clarity rather than being described in the intermediate forms that were gradually built

up during the analytic process. Therefore, the multiple individual codes (some 1,837

in total) and earlier conceptualizations on which this grounded theory is based are

largely not given.



Building bridges to observational perspectives: Describing the core socialpsychological process in psychological therapy in psychosisThe central therapy activity identified was conceptually summarized as a process of

building bridges to observational perspectives. This was defined as a jointly negotiated

process, enacted in the conversation between psychologist and client, based on the

psychologist repeatedly demonstrating the activities involved in observing, or standingback from, experience during the course of conversation with the client. The

psychologist appeared to be continually lending alternative observational perspectives

and the client borrowing these to re-examine distressing experiences and current

concerns, thereby opening up new possibilities for the client’s functioning in the social

world. Essentially, the psychologist seemed to be providing an observational scaffold

to facilitate the client in considering their experiences and concerns from different

perspectives.

Table 2 below gives examples of the core process of building bridges to observa-tional perspectives taken from different therapy session transcripts. It is important

to note that these examples are segments of an ongoing dialogue between these

psychologists and clients, where themes and issues are returned to both within and

across sessions. This represents a particular challenge in presenting succinct examples

of an ongoing dialogical process. Table 3 specifically illustrates the use of research

memos during the grounded theory analytic process and their contribution to the

conceptual development of building bridges to observational perspectives.

Within this grounded theory, the core process of building bridges to observationalperspectives is conceptually understood as the hub of a series of activities and processes

contributing to or arising from it. Key conceptual subcomponents of the building

bridges process are summarized in sections (1–7) below.

Specifying the four main therapy activities comprising building bridgesto observational perspectives: Opening up views; negotiating sharedunderstandings; doing relationship; and managing emotionThe extract given below illustrates the components of building bridges to observational

perspectives defined in sections (1–4). In this extract Liz engaged with Tanya in

examining different perspectives on Tanya’s worry that she would become unwell:

Liz: it sounds like you’re thinking oh, you know, last time someone left, Kevin [staff

member], you got really unwell but I think you were already in the middle of a

really awful (Tanya mm) period and this time maybe you’ll feel sad but it doesn’t

necessarily follow that you would get unwell (Tanya mm-hm) not necessarily. : : : .[14 sec pause] Or am I wrong Tanya? And, and, I’m not suggesting that, am I

underestimating that actually Richard [staff member] leaving does, does really feel,

make you feel quite sad and it’s,//in a considerable way?//

Tanya: //In a way um but.. //the thing is about me Liz is that.. how can I put it? I don’t

really show my emotions very easily (Liz uh-huh, yeah) and then probably I might

sort of break down and cry but.. things that I don’t, I don’t really let things get to

me, do you know, I try not to (Liz yes).. to let, to let, not to let it worry me that

Richard’s gone (Liz yeah) but I gotta face the fact that he’s gone but (Liz yeah), you

know, there’s nothing I can do that he’s gone, he’s just gone. Nothing I can do

about it (Liz right). There’s no point dwelling on the situation that he’s gone

because, you know, I’ll probably end up ill as well in hospital.

(Liz/Tanya-1, 898–917, emphasis in original)



Table

2.Exam

plesofbuildingbridgesto

observationalperspectivestakenfrom

therapysessiontranscripts

PsychologistLizandclientTanyaspeakingintheirthird

taped

therapysession

Psychologist

SueandclientIsabel

speakingin

their

secondtaped

therapysession

Psychologist

LouiseandclientJulietspeakingin

their

firsttaped

therapysession

Tanya:

som

ehow

Istillthinkto

myselfthat,youknow,

I’mtheleastonein

thefamily

it’slikeI’m

the

leastoneto

receiveanythingfrom

mymum,

sheseem

sto

thinkevery,youknowit’slike,as

much

asIdothings

forher

andeverything

(Lizmm)italwaysseem

sto

meto

bethelast

onethat

ever

gets

anythingfrom

her

[:::]it’s

likethey

[fam

ily]seem

tothinkthat..[sigh]I

don’tknow,that

I’msomesort

ofdimwitor

something

Liz:

Mm

why’s,why’sthat

then?

Tanya:

Wellwhen

[brother]was

aliveitwas

likethey

was

alwayssayingto

him..ImeanIknow

they

werethings

he,heshouldn’thavedonethat

he

was

doing(Lizmm-hm)butthey

wouldalways

talkto

him

likehewas

atw

o-yearold

or

something(Lizright)andsort

of..sort

of..

they’dsaythings

tohim

likehurtfulthings

(Liz

right)andspeakto

him

asthough

hewas

likea

five-yearold

orsomething,andas

though

he

didn’tunderstandwhat

was

goingonand

everything,likehisclothes

and,m

ymum

right,

Iusedto

arguewithher

somanytimes,‘cosall

sheusedto

goonaboutwas

theway

thatIw

as

dressed

(Lizmm-hm).Sheeven

does

itno

w

sometimes

youknow

but..

Liz:

Sodoyouthinkthey’retreatingyounow

ina

way

they

talked

to[brother],inthesameway?

Isabel:

‘cosmymind’svery

active

itfeelslikelyit

should

bedoingthings

allthetime(Suemm)

it’slikeit’sallgo

Sue:

//Isthat,isthat

fairto

dothings

allthetime

doyouthink//

Isabel:

//It’snotfairbut,butit’snotfairno//because

I

remem

ber

when

Iusedto

work..Iusedto..be

allgo

andImademyselfilloverit..

Sue:

..so

itisimportantto

havetimeto

yourself?

Isabel:

Soitisimportant,yeah

so(Sueright)when

I

feelyouknowlikeI’vehad

arestandwehavea

goodlaugh,when

theother

dayscomeIfeel

more

energy

to[lookaftermyself](Sueyeah).

Youknowmore,m

ore

energy

forother

things

(Sueyes,yes)

[:::]

Sue:

Sopositive

affirm

ationalso

lookingat

what

youhaveachieved:::.[6sec]

because

it’sthat

confidence

whichisactuallyyouknow..helped

youtake

lotsofstepsforw

ardanditcontinues

tohelpyoutake

lots

ofstepsforw

ard(Isabel

mm)..withoutrushingitneedsto

begradual

when

you’reready(Isabel

mm)

Isabel:

..Yeah

justtake

itslowlylike,likeI,allI

justtake

itas

itcomes

Imeannaturally,it’s

naturally

slowlybecomingnaturally

each

day

(Sue

mm,yes,yes)..soit’s,it’s

notlike

Ishouldpush

myselfIjustwantedto

[inaudible]likeitjusthappened

when

Louise:

Andsince

you’vebeenbackto

work

you

haven’tfeltthat

peo

pleweretalkingabout

you//ormockingyouat

all?//

Juliet:

//Notat

all//notat

all

Louise:

Butit’sthesamepeo

ple//

Julie:

//Ifinditmore

loving,receptive

peo

ple(Louise

mm).That

sometimes

when

Icomeoutofthe

environmentIsee

them

andthey,thesearethe

samepeo

ple

that

havebeenmockingand

laughingandjestingaboutthis(Louisemm,)

what

had

transpired

within

thispasttw

o

monthsthatI’vebeenaw

ay.C

ouldithavebeen

methat

has

changed(Louisemm)orcould

it

havebeenthem

that

has

becomeabitmore

sensitive

tom

yfeelings.It’s

kindoflikeum

not

havingreallyfoundtheansw

er//[can’thear]//

Louise:

//It’sapuzzleisn’tit?//

Juliet:

Yeah

Louise:

It’s,it’s..itsoundslikeit’severybody(Juliet

yeah)at

work’schangednotjust

oneperson

(Julietyeah).They

allseem

different(Juliet

yeah)to

you(Julietyeah)um..

Juliet:

ButIfounditmore

lovingpeo

ple..(Louise

mm)more

caringpeo

ple

Louise:

Doyouthinkanything’sdifferentabout

you,

betweenwhen

youwereat

work

before

and

now?



Table

2.(C

ontin

ued)

PsychologistLizandclientTanyaspeakingintheirthird

taped

therapysession

Psychologist

SueandclientIsabel

speakingin

their

secondtaped

therapysession

Psychologist

LouiseandclientJulietspeakingin

their

firsttaped

therapysession

Tanya:

Yeah,er

yeah

Liz:

Andwhy,why

doyouthinkthat

is?

Tanya:

WellI’m

theoldestonenow

and

because

[brother]ain’taroundit’seven

worse..it’slikeum

basicallyI’m

atthe

bottom

ofthelist

Liz:

Itsounded,because

you’retheoldestone

[they

think]

youshould,youshould

do

more

andyoushouldn’tbeable

to//do

more

foryourself//andyoudon’twant

support,somethinglikethat?

Tanya:

//Do,doyeah//NoIshould

beable

todo

more

forthem

(Lizbutthen).Butwhy

should

Idoit?(Lizyeah).Idon’tlivethere

anym

ore

doI?(Lizno)

(Time3tape,

843–897,em

phasisin

original)

Istartedwork

andgoingto

churchand

cooking,allofasudden

itjust

happened,

that’show

therest

willcome//hopefully//

Sue:

//More

naturally//

Isabel:

Yeah

that’show

Ifeelmaybetherest

will

comemore

naturally//in

time,

intime,

yeah//

(Time2tape,

994–1072)

Juliet:

Yeah

because

peo

plesay,peo

plecomplim

entnow

thatI’m

abitcheerful(Lo

uiseright)..even

though

I’mgoingthrough

asituationat

homeI’m

more

cheerful..at

work

um,probably[m

ore]relaxed

than

Iusedto

be(Louiseyeah)probablythey

usedto

seehowtense

Iwereand[:::]so

I..feel

very

good,before

allIwas,was

desperateto

get

outoftheplace

(Louiseyeah)//

Louise:

//It’sakindofa

sortofviciouscircleisn’tit?(Juliet

yeah)Ifyou’refeelingtense

andstressed

(Juliet

yeah)then

peo

ple..(Julietreact)aren’tbeing

kindofw

arm

andkindto

you(Julietyes)they’re

beingabitstand-offish,yougonnafeelmore:::

more

youknow

(Julietyeah)uncomfortable

in

theirpresence

aren’tyou(Julietyeah,yeah)and

then

you’regonnafeelmore

stressed

(Julietyes)

(Time1tape,

151–199,em

phasisin

original)

Tran

script

ion

Key.[text],explanatory

note;[:::],sectionomitted;//,interruption;////,both

speakingat

thesametime;..,pause

(,5seconds).



(1) Opening up viewsOpening up views was defined as the therapist encouraging the elaboration of the

explanations and views available to the client in considering an area of distress. This

activity was understood as being supported by the psychologist offering specific

understandings of psychosis (defined as the subcategory developing explanation).

(2) Negotiating shared understandingsNegotiating shared understandingswas defined as a constantly negotiated sharingof views

between therapist and client during the course of conversation to enable them both to

Table 3. Extracts from research memos summarizing sequence of psychologist and client therapy

session activities

Mark/Colin-1 Sequence of activities within session (analytic codes in italics)

Colin starts to tell a ‘story’ about a difficult situation, gets caught up in description, an immediacy aboutthe experience and struggles to articulate the exact nature of mental experience

Mark actively encourages the telling by actively listening, acknowledging, summarizing

Colin uses analogy to convey aspects of experience and summarizes main concern after describingthe situation

Mark restates the summary and moves the dialogue on by reframing the key aspect of the troublingexperience within a particular model, or suggests ways of coping, or reinforces Colin’s attemptsat coping

Colin (partially) accepts the reframe predicated on a model of experience (Colin’s implicit understandingof how things are)

The sequence repeats with Mark restating his conceptualization and Colin telling other stories aboutdifferent situations. Mark explicitly maintains a thread through the session connecting the segmentswhilst Colin implicitly does this through telling stories which seem connected by particular themes.How far is Colin aware of this?

(extract from memo dated 2nd July 2003)

Sue/Isabel-1 Sequence of activities within session (analytic codes in italics)

Isabel states worst:not self as should be ( falling short)caught up in story

Sue not accepting Isabel’s account at face value:questioning Isabel’s assumptions about self and othersreminding of disconfirmatory experiencesemphasising achievements

Isabel hears self afresh (possibly indicating reflective activity)Sue restates discrepant view

Isabel states worst (again)Sue not accepting at face value

Isabel hears self afreshSue restates discrepant viewIsabel accepts Sue’s reframing (at end of session)

(Extract from memo dated 15th January 2004)



move towards shared alternative perspectives on the client’s distress. In commonwith the

category of opening up views, this process was seen as making available new possibilities

for thinking, feeling, or acting in relation to areas of distress, as Colin described: ‘It’s like

finding the answers together. Do you see what I mean? (SD yes) Resolving it together. Like

he’ll [psychologist] help you, he’ll come up with an idea, you say ‘well not really, that

doesn’t work forme, that [other idea]might do’, and he somehowchannels it in. You don’tactually have the answer but it takes two of you to find it’ (T2 interview, 299–302). The

analysis suggested that the shared understandings developed via this joint process had

utility insofar as they offered the potential for opening up alternatives for thinking, feeling,

or acting rather than in any absolute truth-value.

However, it was clear that these psychologists particularly emphasized some

understandings over others as they focused on some lines of discussion, ignored others,

and offered their own understandings specifically through developing particular

explanations of psychosis. The psychologists developed explanations of psychosis thatemphasized agency and self-worth, and minimized self-blame, as the extract below

illustrates:

Louise: when you told me the story of what had happened to you (Juliet yeah) in this

country ( Juliet yeah) um and what I heard was somebody who was you know

very intelligent, very ambitious and that you tried to hang on to your [ : : : ]career but there were lots of practical reasons about being here (Juliet yeah)

that made that very hard (Juliet yeah) and you’d been let down by the woman

that you stayed with (Juliet yeah) and for understandable reasons had felt you

know felt a bit hopeless, and perhaps felt that you couldn’t trust people.

(Louise/Juliet-1, 354–362, emphasis in original)

(3) Doing relationshipDoing relationship was defined as an active, reciprocal process of the psychologist and

client working together in creating and experiencing a confiding context. Conceptually,doing relationship is a summation of the joint, and individual, activities and

experiences of psychologist and client being engaged in a relational process. However,

the psychologists’ strategic use of activities implied that they particularly assumed

responsibility for the maintenance of dialogue. Doing relationship then was

characterized by the psychologist taking the lead in creating a confiding context in

which the client can make known their concerns and therefore experience a confiding

context. The extract from Liz/Tanya-1 (lines 898–917) given earlier, where Liz

collaboratively infers Tanya’s disagreement with her alternative explanation of distress,illustrates how doing relationship is inherent in the building bridges process.

Doing relationship emerged as a complex set of interrelated psychologist and client

activities (see Figure 1 below). So, for instance, the therapist demonstrating concern not

only related to the client feeling cared about, but also related to the client building up

trust in the therapist and valuing self: ‘she [psychologist Liz] makes me feel like I’m

someone special as well, that I’m worthy’ (Tanya, T1 interview, 804–805).

(4) Managing emotionManaging emotion was defined as the psychologist regulating the emotional pace of

therapy through actively structuring the conversation in order to minimize the client

getting caught up in experience. Liz’s actions in acknowledging Tanya’s distress (lines

898–917 above) represent this type of psychologist activity. Although the clients also



engaged in managing emotion at times, it seemed that this was done in a less systematicway than by therapists.

Conceptualizing the link between building bridges to observational perspectives andthe social world: Opening up new possibilities; processing distress; and enhancingagency and self-worthOpening up new possibilities, processing distress, and enhancing agency and self-worth

were conceptualized as arising inherently from the core process of building bridges to

observational perspectives and summarize processes through which therapy activities

are understood to influence the client’s functioning in the social world.

(5) Opening up new possibilitiesThe availability of new possibilities for thought, feeling, or action in the client’s social

world appeared to arise from the client making explicit and elaborating experiences,

meanings, and explanations in dialogue with the psychologist. The earlier extract from

Colin’s T2 interview (lines 299–302) and that below illustrate the sense of new

possibilities that can arise from the building bridges process:

Juliet: [She is] helping me to understand what the difficulties in my life were, helping

me to come to terms with it and helping me to look for a way forward [ : : : ] Butwhy personally I haven’t even thought of that, ‘cos I’ve been preoccupied with

that over the period of time (SD yeah) and, you know, wallowing in self-pity,

‘why me, why do I have to go through, why do, people don’t understand?’ That’s

how I’ve been looking at it (SD yes). But I never asked myself, how do you move

on (SD yes mm)? And that’s where the difference comes with talking with her as

a psychologist (SD I see yeah). That’s where the turning point is..

(T1 interview, 557–572, emphasis in original)

Figure 1. The subcategories of doing relationship and its links to other major components of the

building bridges process.



(6) Processing distressProcessing distress was defined as clients standing back from distressing experiences,

memories, or concerns such that clients were no longer getting overwhelmed by

emotion in speaking about them (and by implication in thinking about them).

Processing distress appeared to be facilitated by the client and psychologist structuring

distressing experience in a conversational account, thereby allowing distress to becomethe object of observational activities. For Juliet, this seemed to allow her to act

differently outside of therapy, whereas Tanya implied she still relied on her psychologist

to assist her in processing distress:

Tanya: I get really worried and frustrated about something and then I’ll go and tell Liz

[psychologist] and she says, well that it feels like I’m making a mountain out of a

molehill (SD mm). Why, why was I so keyed up and worried. [ gives example

discussed with Liz : : : ] it didn’t seem like nothing to worry about in the first

place, I don’t know what I was so worried about.


Juliet: since talking with Louise [psychologist] I’ve now understood that some of the

thoughts that have been at the back of your mind.. has affected you in such a way

that it was affecting human relationship (SD mm), and affect your outlook about

life and positive way of doing things [ : : : ] when such thoughts try to cross um in

mymind and say ‘oh you’ve been through this, you’ve been through that’, [I] kind

of dismiss it, unlike before when I would spend time (SD mm) thinking about it,

preoccupied with it, it affects my mood, it affects my relationship, it affects

everything around me (SD mm) and keep me in perpetual.. kind of bondage.

Now I tend to dismiss such thoughts and look forward to moving ahead.


Processing distress seemed to be facilitated by sharing understandings of distress thatwere

more complex than those already held by the client, minimized self-blame, emphasized

the client’s active attempts to cope, and could be shared socially with at least some people.So, Louise and Juliet appeared to have worked together during a series of therapy

conversations to develop a richer understanding of Juliet’s experiences, one recognizing

multiple influences leading to the development of psychosis: ‘Juliet: it’s not the pressures

of the job affecting me (Louise mm) in a way that contributed to my problems (Louise

okay). But looking back at my life from the time I step into this country, to the relationship

that I had, the people that I mixed with, the kind of job that I did (Louise mm) a

combination of all these things’ (Louise/Juliet-1, 338–342, emphasis in original)

In contrast to processing distress, getting caught up in experience was defined as theclient getting stuck in immediate experience and therefore being unable, at that point, to

take an observing position in relation to their distress or concern. The effect appeared to

be one of reducing access to a consensually shared (or negotiated) view of the world, and

to a taken for granted sense of an external reality, thereby causing difficulties for the client

in functioning in the social world: ‘you’re walking down the street and colour changes..

lights, the sky, everything, the walls, everything just changes shape and you’re just like

‘huh’, you know, you realise afterwards but in it you don’t’ (Colin, T1 interview, 388–391,

emphasis in original). For Andrew it seemed that some of the experiences specificallyassociated for him with psychosis contributed to Andrew becoming socially isolated as he

withdrew frompeople as a result of his assumptions about their intentions: ‘I thought, sort

of thought [intake of breath] people were against me um.. and well I probably thought



every, everyonewas against me um and um.. I sort of think that’s perhaps not the case now

so.. so I think aboutotherpeople in a better light’ (Andrew,T1 interview, 450–454).Getting

caught up in experience appeared to followunexpected perceptual changes associated for

these clientswithpsychosis but, in addition, it also occurredwhen talking about any area of

distress, implying an overwhelming of observational perspectives by emotion.

The following extract gives an example of getting caught up in experience occurringin the therapy session itself as Colin attempted to describe the pressures of studying

shortly after leaving hospital, following a general opening question from his

psychologist Mark about how his week had been:

Colin: How it’s been? Um.. k.. very tired (Mark mm) I’ve been very like, I’ve been

studying a lot (Mark mm mm).. um.. but I’ve been kind of.. feeling kind of really

tired out, my eyes are burning up and.. stuff but that’s about it, you know, that’s

like that side of it, you know, cos that’s taking up a lot of my time, mental time,

thinking time, the lot, I mean all the days I’m not in there (Mark yeah) I’m just ff,

because we get tested every two weeks it’s, I feel the strain. But I’m pushing

myself through that strain (Mark mm) you know what I mean? (Mark yeah) Some

people in the class, which I’ve noticed, are just sort of skipping through it, you

know. Like ‘oh it’s no problem, bl, bl, bl’, you know. I mean I’m reading notes, I

mean I, in the first part I got nine out of nine I passed the.. the thing, you know

(//Mark that’s great yeah//) completely but.. that’s cos I really pushed through it

and now I’m going through that again, you know, now Friday’s coming up and

it’s another test and then we’ve got another two weeks after that (Mark mm

mm), again, er it was gonna be harder than for the last two weeks.

(Mark/Colin-1, 16–32, emphasis in original)

(7) Enhancing agency and self-worthFinally, enhancing agency and self-worth conceptually summarized the enabling effect

of the building bridges process in highlighting the client’s qualities and abilities. Therewas an emphasis in the psychologists’ activities on making explicit the clients’ qualities,

abilities, and instances of agency; thereby both drawing these to the clients’ attention

and giving hope of better outcomes.

SD: Has talking with [psychologist] had any effect on how you feel about yourself?

Colin: Yeah a better person (SD mm).. straightaway you know. That’s it. Just feel more

confident (SD right.. right). In my abilities [ : : : ] Nothing’s really stopping

me (SD mm). It’s just how I feel inside (SD yes). So he’s made me feel a more

confident, able person in that way. I can’t say more than that really.


Anna: she’s [psychologist Lee] the one that sort of like encouraged me, ‘it will get better

and they will take you off the medication as soon as you get well and you can

begin to lose the weight when you come off the medication, you can start work,

you can decorate your flat, go out, meet people, see your family, be happy and

see different things’ (SD mm) and she gave me a lot of confidence, she gave me

hope (SD right) to try.. to try, and instead of just, you know, just giving up (SD

mm) and thinking ‘oh no I’m gonna be ill forever (SD right), on the medication

forever, oh there’s no point in living because (SD mm) I’m not like other people,

you people’ and things like that.

(Anna, T1 interview, 191–200, emphasis in original)



Figure 2 outlines the key therapy processes comprising building bridges to

observational perspectives and the processes through which building bridges is

understood to affect the client’s functioning in the social world.

Discussion

Building bridges to observational perspectives conceptualizes a central dialogical

process of standing back from experience operating during therapy in psychosis and its

role in assisting the client in managing distress and functioning in the social world.

This process is supported (scaffolded) by the therapist repeatedly demonstrating the

activities involved in observing experience during an ongoing conversation, effectively

building bridges between different perspectives and the new possibilities for action,

thought or feeling allowed by them.

The analysis suggested a dialogical basis to objectifying private experience and thussupported Leiman’s (2000) view of reflexivity as an ongoing, conversational process of

objectifying experience that can be facilitated through dialogue with another person

(a therapist). This study developed Leiman’s view of reflexivity by specifying how it was

enabled by psychologists in therapy conversations with individuals experiencing

psychosis. In addition, our analysis suggested that this conversational activity could

occur on a continuum from an entirely private, inner dialogue to a public dialogue (with

a therapist). Where our analysis differs from Leiman’s definition of reflexivity is in the

suggestion that either of these could be helpful to the person experiencing psychosis inprocessing distress and functioning in the social world. There was some suggestion from

the analysis that for some clients (e.g. Andrew, Juliet, and Colin) the externally

scaffolded, dialogical process of standing back from experience became internalized as

an inner dialogue, as Leiman (2000) and Vygotsky’s (1978) ideas would suggest.

However, for others (e.g. Tanya, Isabel, and Anna) it seemed this continued to depend

on the psychologist’s support of the building bridges to observational perspectives

process within therapy sessions. However, in the absence of any systematic examination

of outcome in the current study this must remain speculation.There is a common idea shared by this study and work from a variety of theoretical

perspectives (e.g. Blenkiron, 2005; Dimaggio et al., 2003; Jørgensen, 2004; Lombardi,

2003; Seikkula & Trimble, 2005) that developing new meanings, attributions, dialogues,

or narratives, has a potentially transformative effect for the client’s experience of self-

Figure 2. The key grounded theory subcomponents of building bridges to observational perspectives.



hood and their relationship to the social world. More particularly, the conceptualization

of therapist activities in the building bridges to observational perspectives process

appears consistent with Stiles’ (1999) and Brinegar et al.’s (2006) conceptualization of

the role of creating ‘meaning bridges’ between different internally and externally

available perspectives in facilitating change in therapy with other forms of distress than

psychosis. This implies that processes identified as important in this study of therapyin psychosis might parallel those operating in therapy with other forms of distress.

In another interesting and specific parallel with the findings from the current study,

Seikkula and Trimble (2005) emphasize the importance of ‘emotional regulation’

(p. 471) happening alongside the opening up of new understandings in therapeutic

conversations in their account of family work with people experiencing psychosis.

Finally, the conceptualization of building bridges as a complex set of inter-related

therapist, client, and joint activities enacted in an ongoing conversational cycle seems to

fit with Stiles et al.’s (1998) responsiveness model of therapy processes rather than withlinear models linking therapy process and outcome.

It is also interesting to note, in terms of what might be called conceptual

convergence, some parallels between specific constructs emerging from this

grounded theory analysis and ideas derived independently from Hirschfield, Smith,

Trower, and Griffin’s (2005) study of the personal experience of psychosis and

additionally from Davidson’s (2003) and Lysaker’s work (Lysaker & Buck, 2006;

Lysaker, Lancaster et al., 2003; Lysaker & Lysaker, 2002; Lysaker et al., 2001; Lysaker,

Wickett et al., 2003) on recovery from schizophrenia (sic). Hirschfield et al.

conducted a grounded theory analysis of six young men’s reports of the experience

of psychosis. In common with our study, they noted the disruption caused by

perceptual changes to ‘everyday assumptions about the world’ (p. 265) and the

importance of individual meaning making in integrating psychotic experiences into a

revised sense of self. What was striking from considering Davidson’s (2003)

phenomenological analysis in relation to the current study was the parallel

emergence of the importance of personal meaning making, a sense of agency and

hope, and reconnecting with the social world in recovery from psychosis. Similarly,Lysaker and colleagues’ STAND measure, developed through literature review and

analysis of therapy transcripts, identifies several outcome domains analogous to

concepts emerging as important in the current study: namely, ‘social worth, social

alienation, personal agency’ (Lysaker et al., 2003, p. 538). In a further parallel,

Lysaker et al. (2001, p. 259) suggest five aspects of psychotherapy for schizophrenia

(sic) that might assist in narrative enrichment and hence, they suggest, in recovery

through increased self-awareness and personal agency: (i) developing a story of what

problem the person is facing; (ii) developing a story of aspects of the self not affectedby the problem; (iii) ‘envisioning the future’ (p. 259); (iv) processing affect to reduce

distress; and (v) ‘enactment or action on the basis of narrative revisions’ (p. 259).

Our study supports this view but suggests in addition that what is particularly

important is the development of understandings of distress that are both personally

acceptable, in terms of their implications for a sense of agency and self-worth, and

amenable to being shared socially. That is, this analysis suggested it is the client’s

interpretation of the various explanations possible for the experience of psychosis

that is important, not the specific explanation per se.Of course, it must also be recognized that this grounded theory represents a

beginning in conceptualizing processes in psychological therapy in psychosis

developed from one study with a specific dataset. There are a number of avenues



potentially open to further develop and challenge the model that draw on different

traditions of systematic inquiry. Further qualitative studies based on different datasets

would provide multiple perspectives on this issue (Guba & Lincoln, 1998), potentially

demonstrating conceptual convergence. Quantitative examinations of this grounded

theory would involve testing hypotheses that can be derived from it with larger samples

of data. Such hypotheses might include specifically testing whether building bridges is acommon process in psychological therapy in psychosis regardless of the theoretical

orientation of the therapist or, indeed, examining whether building bridges to

observational perspectives might be a common process in psychological therapy with

forms of distress other than psychosis, given parallels with constructs such as ‘meaning

bridges’ emerging from more general psychotherapy research.

What this grounded theory of building bridges to observational perspectives

particularly contributes to understanding therapy in psychosis is the specification of

the central role played by a dialogical process of standing back from subjectiveexperience in the client managing distress and functioning in the social world and

the specific therapist activities involved in scaffolding this process during therapy

conversations.

Acknowledgements

This paper presents work completed by the first author to fulfil the requirements of a PhD in

Psychology at Birkbeck College, University of London, and The Tavistock Clinic, and was partly

supported by South London and Maudsley NHS Foundation Trust. The authors are grateful to the

clients and psychologists who generously allowed access to their therapy sessions and to their

views on the therapy process.

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Received 13 October 2006; revised version received 1 February 2008


Building bridges to observational perspectives: A grounded theory of therapy processes in psychosis

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