Introduction

Psychological conceptualisation of psychosis was first attempted by the founding father of psychotherapy: Sigmund Freud (1911). He considered psychosis to be a narcissistic process resulting from withdrawal of libidinal energy from the external world (decathexis) to the sufferer's ego (Freeman, 1977). In such cases he considered psychological work impossible as no transference could be established between the therapist and the patient.

Eugene Bleuler invented the hallmark term schizophrenia and conceptualised psychosis as splitting of thinking and feeling (Bleuler, 1911). His psychological explanation for psychosis was influenced by Freudian theory. His son Manfred Bleuler, in a follow up study of 208 patients, first demonstrated that a proportion of patients with schizophrenia recovered or improved over time (Bleuler, 1978). However, Kraeplin's observational study on schizophrenia (Kraeplin, 1919) was much more powerful in shaping the view of schizophrenia as a deteriorating illness where improvement was a relative rarity. Jaspers, the existential phenomenologist, placed a great emphasis on the form of symptoms rather than the actual content (Jaspers, 1963). Delusions and hallucinations became characteristic symptoms of psychosis, albeit with scant regard to the actual content or meaning behind the symptoms. Later theorists like Laing (1960) and Szasz (1960) tried to enlarge upon a postulated meaning behind the symptoms of psychosis but the approach was lost in the rhetoric of the antipsychiatry movement, with little formulation of any therapeutic approach.

Harry Stack Sullivan saw schizophrenia as a problem of human connectedness and espoused an active role of the therapist as a participant observer (Sullivan, 1962). Varied attempts by different thinkers led to fashionable theories of different times like the stigmatising 'schizophrenogenic mothers' theory (Fromm-Reichmann, 1950), marital schism (Lidz,

Handbook of Evidence-based Psychotherapies: A Guide for research and practice. Edited by C. Freeman & M. Power. Copyright © 2007 John Wiley & Sons, Ltd.

Fleck & Cornelison, 1965) and double-bind communications (Bateson, 1962) in families with individuals affected by schizophrenia. All of these studies had severe methodological drawbacks and are now consigned to the history section of chapters on schizophrenia.

The biological origins of schizophrenia were not in doubt when the serendipitous discovery of chlorpromazine led to a reasonably effective short-term treatment of positive symptoms of schizophrenia (Meyer & Simpson, 1997). Twin studies, brain imaging and neurotransmitter studies established the biological model for understanding the schizophrenic process. This was largely an expansion of Jasper's form-based classification of symptoms and Kraeplin's hypothesis of schizophrenia as a 'brain disease'. Yet, in the same period, evidence had accumulated that schizophrenia had a significant psychological component, as apparent by an increase in negative symptoms in impoverished environments (Wing & Brown, 1961) and by the successful application of behaviour modification (Bellack, 1986) in case studies of behavioural disturbances in schizophrenia. The IPPS study (WHO, 1973) distinctly proved that the incidence of 'process schizophrenia', as defined by first-rank symptoms was similar across the countries but the outcome of schizophrenia was better in developing countries. This finding was confirmed in a 10-year follow up study (Jablensky et al., 1992). One could argue that there were more psychosocial rather than biological differences between citizens of different countries, and therefore the outcome of schizophrenia could be influenced powerfully by psychological factors. However, the spate of exclusive biological hypothesisation continued in the face of evidence for psychosocial factors influencing the course of schizophrenia. The success of antipsychotic therapy lead to mass de-institutionalisation programmes (Thornicroft & Bebbington, 1989) across the world. This paradoxically led to a closer psychological encounter between society and the sufferer with schizophrenia. However, despite the efficacy of drug therapies, a proportion of patients continued to be unwell and several underwent periodic relapses (Lehman et al., 2004). This highlighted the problem of mental illness in communities and families. The success and failure of drug therapies paradoxically reignited psychological thinking about schizophrenia.

Before the reader delves further into this chapter, it would be pertinent to point out that psychological therapies for psychosis are not stand-alone interventions. There is ample evidence that antipsychotic treatment is the mainstay of therapy in schizophrenia (Lehman et al., 2004; NICE, 2002). Psychosocial interventions are added to enhance the management of schizophrenia and reduce the burden of the condition on the individual sufferer and the family. The rest of this chapter will examine the development of an evidence base in psychological interventions in schizophrenia.

Anxiety and Depression 101

Anxiety and Depression 101

Everything you ever wanted to know about. We have been discussing depression and anxiety and how different information that is out on the market only seems to target one particular cure for these two common conditions that seem to walk hand in hand.

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