Purpose Research on recovery from psychosis indicates that individuals often continue to experience high levels of distress in coping with day-to-day life, even after the psychotic phenomena have ceased. Researchers have suggested that this discrepancy can be explained by difficulties in mentalising, a process closely associated with attachment security. This review focuses on psychotic experiences insofar as they intersect with trauma, attachment disturbances and dissociative processes, while acknowledging that psychosis is heterogeneous and may also be understood through other frameworks. The present review aimed to answer the question: ‘What is the role of mentalising in recovery from psychosis?’. Methods A search, following systematic principles, of four databases was performed (Web of Science, SCOPUS, PsycINFO, Medline EBSCO). After screening for relevance and quality, 15 articles remained. Critical interpretative synthesis (CIS), a review methodology born from meta-ethnography, was used to allow inclusion of data across a range of sources. This enabled the synthesis of information drawn from both qualitative and quantitative studies, alongside expert opinion papers and case studies. Results The results indicated that mentalising capacity underpinned reciprocal processes of developing sense of self (through self-reflection and developing complex self-narratives) and adaptation to the social environment (through attachment security and the ability to think about interaction). This in turn afforded agency in communicating self-states, accessing social connection and support, navigating social interaction, and a return to meaningful activities. Mentalising in recovery also influenced subjective experience, including feeling connected, reduced self-stigma, an integrating recovery style, a reduction in unusual experiences, and a sense of self continuity. Conclusions The original contribution of this review is the development of a conceptual model linking mentalising to recovery through two reciprocal pathways: re-development of a sense of self and adaptation to social environments. The proposed model should be regarded as a clinician- and literature-derived framework based on a heterogeneous corpus, requiring validation through further study centred on first-person accounts.

BackgroundPsychosis is increasingly being viewed as another form of complex post-trauma experience. Despite this, psychosis-specific trauma therapies remain underdeveloped due to fears they may cause stress. Treating complex trauma has particularly been avoided in psychosis. Eye Movement and Desensitisation Therapy (EMDR) is argued to be a theoretically compatible treatment for psychotic phenomena by storing distressing trauma memories into a more adaptive state. Qualitative research exploring the acceptability of this novel, potentially controversial, treatment, is limited.MethodsTen participants were interviewed using Interpretative Phenomenological Analysis (IPA) to enable in-depth exploration of experiences of EMDR targeting trauma memories in psychosis.ResultsThree Group Experiential Themes (Readiness, An Extraordinary Process, Transformations) and nine subthemes emerged. The themes arose like a journey, representing the different stages of the EMDR experience, including engagement, the unique EMDR process and the perceived impacts of EMDR on participants' lives.DiscussionThe results are connected to existing EMDR theory and its tailored application to psychosis. The implications for clinical practice and future research for this novel treatment approach are discussed.

Clinicians attempting to use EMDR with clients who experience psychosis may struggle to identify and access the trauma memories underlying the psychotic experiences. This may be due, in part, to the prevailing illness model and the traditional exclusion of psychosis from trials of EMDR. This paper aims to provide suggestions and guidance for clinicians developing their EMDR practice with psychosis. The paper describes five methods that may be useful clinically to identify the trauma memories. In order to support case conceptualisation, a mapping template is introduced and described. As dissociation and avoidance may complicate accessing trauma memories for reprocessing, techniques to work with these in psychosis are described. Future directions for both clinical and research work are considered.

Evidence has been accumulating for the crucial role that trauma plays in the development of psychotic experiences. As such, there has been increased interest in the use of trauma-focused therapies, like Eye Movement Desensitisation and Reprocessing therapy (EMDR), for people who experience psychosis. However, the medical model has traditionally understood psychosis as a brain disease, leading to conceptual confusion regarding the role of trauma memory networks in the development of psychotic experiences. This paper proposes a trauma-informed understanding of psychosis in accordance with the Power, Threat, Meaning Framework (PTMF). The commonalities between the PTMF and the key models employed in EMDR, i.e. the Adaptive Information Processing and Structural Dissociation models, are explored.

Background. In psychosis, the prime indicator of outcome has been relapse, but hospital readmission can no longer be used for this purpose. Researchers now require methods for assessing relapse that are objective, blind, reliable and valid. We describe the reliability and validity of such a technique using case-notes. Method. Information from routine clinical notes of participants in the Lambeth Early Onset (LEO) study (less all references that would unblind the assessor) were recorded on a form divided into 1-month sections. Operational definitions of remission and relapse enabled clinicians to identify remissions and relapses blindly from the summary information. We calculated reliability regarding both the fact and the timing of remission and relapse. PANSS ratings at 6 and 18 months provided a measure of validity. Results. The kappa value for the identification of remission by individuals ranged from 0·64 to 0·82, while that for consensus between paired raters was 0·56. The corresponding values for relapse were 0·57–0·59 and 0·71. Intra-class correlations for time to remission and to relapse were very high. Raters guessed correctly whether the participants came from the intervention or control group on 60–75% of occasions. Independent PANSS ratings were strongly related to the remission/relapse status of participants. Conclusions. The reliability of the technique described here was moderate to good, its validity was good, and it provides a useful and timely addition to methods of evaluating remission and relapse in psychosis. On the basis of our experience, we recommend consensus rather than individual ratings.

Clinicians and researchers have suggested that rapidity in belief formation, due to having a high ‘need for closure’ (NFC), may contribute to the acceptance of delusional explanations. The aim of the study is to determine whether NFC has such a direct link with delusions. A secondary aim is to examine if NFC is related to the delusion-associated reasoning process of ‘jumping to conclusions’. One hundred and eighty-seven patients with psychosis, recruited for a treatment trial of psychological therapy (the PRP trial), completed the Need for Closure Scale (NFCS), symptom measures, and probabilistic reasoning tasks. The NFCS was considered in terms of its two dimensions: a desire for simple structure and a preference for quick, decisive answers. The individuals with psychosis reported being poor at making quick, decisive answers but required a greater need for simple structure. NFC was associated with levels of anxiety and depression. There were weak links between NFC and both positive and negative symptoms of psychosis, but these were explained by differences in affect. NFCS scores were unrelated to jumping to conclusions. Contrary to the argument that NFC is directly linked to delusions, individuals with delusions actually perceive themselves as indecisive. There was no evidence that NFC—at least as assessed by the NFCS—could be a proximal cause of delusions. Any potential effect on psychotic symptom presentation is indirect, mediated through affect. The use of the NFCS on its own in the study of psychotic symptoms cannot be recommended.

This study investigated the role of need for closure (NFC) and anxiety in delusions. The Need For Closure Scale (NFCS) and measures of trait and state anxiety were administered to an early psychosis group with current delusions, a clinical (generalised anxiety disorder—GAD) control group and a non-clinical control group. The battery of questionnaires was repeated at follow-up one year later. The NFCS did not meet criteria for a unidimensional scale and two sub-scales were removed from all further analyses. At baseline the deluded and GAD groups scored significantly higher on the reduced NFCS (NFCS-R) than the control group. Trait anxiety was related to NFCS-R in the GAD and non-clinical control groups, but not in the deluded group. At follow-up all groups scored significantly lower on the NFCS-R, perhaps suggesting a practice effect, although the two clinical groups continued to have higher scores than the non-clinical control group. The recovered and non-recovered deluded groups did not differ on the NFCS-R one year later, unlike in the GAD group where recovered participants had significantly lower scores than the non-recovered. Change scores on the NFCS-R and trait anxiety were correlated at trend level in the GAD and non-clinical control groups, but not in the deluded group. These findings suggest that whilst NFC and trait anxiety are related in non-psychotic groups, NFC may be implicated in the formation of delusions, independently of anxiety, in psychotic individuals.