Managing Stigma Effectively: What Social Psychology and Social Neuroscience Can Teach Us (2015)

As I mentioned earlier, I’ve internalised a lot of things that impede my recovery and add to the continuing burden of my illness. It’s good to see an article addressing stigma:

Managing Stigma Effectively: What Social Psychology and Social Neuroscience Can Teach Us

Psychiatric education is confronted with three barriers to managing stigma associated with mental health treatment. First, there are limited evidence-based practices for stigma reduction, and interventions to deal with stigma against mental health care providers are especially lacking. Second, there is a scarcity of training models for mental health professionals on how to reduce stigma in clinical services. Third, there is a lack of conceptual models for neuroscience approaches to stigma reduction, which are a requirement for high-tier competency in the ACGME Milestones for Psychiatry. The George Washington University (GWU) psychiatry residency program has developed an eight-week course on managing stigma that is based on social psychology and social neuroscience research. The course draws upon social neuroscience research demonstrating that stigma is a normal function of normal brains resulting from evolutionary processes in human group behavior. Based on these processes, stigma can be categorized according to different threats that include peril stigma, disruption stigma, empathy fatigue, moral stigma, and courtesy stigma. Grounded in social neuroscience mechanisms, residents are taught to develop interventions to manage stigma. Case examples illustrate application to common clinical challenges: (1) helping patients anticipate and manage stigma encountered in the family, community, or workplace; (2) ameliorating internalized stigma among patients; (3) conducting effective treatment from a stigmatized position due to prejudice from medical colleagues or patients’ family members; and (4) facilitating patient treatment plans when stigma precludes engagement with mental health professionals. This curriculum addresses the need for educating trainees to manage stigma in clinical settings. Future studies are needed to evaluate changes in clinical practices and patient outcomes as a result of social neuroscience-based training on managing stigma.

Particularly interesting is the following passage:

“The most difficult of all stigmatizing processes to counter is perhaps internalized stigma. Internalized stigma results when stigma of whatever specific type becomes a lens for self-perception that is judgmental, contemptuous, and dismissive. Patients feel disgust for their identity as psychiatrically ill. Compassion for self is difficult to muster. Loss of self-esteem, a sense of alienation, social withdrawal, and self-hatred are common sequelae.

During categorical social cognition, the sociobiological systems stream information about the social world through the rostral anterior cingulate gyrus where it can be compared to a model of expectable reality that has been constructed by the prefrontal cortex from memory retrieval. Detecting a mark of stigma in a person’s environment appears to generate conflict between incoming sociobiological information and an expectable reality. When the anterior cingulate gyrus detects this conflict, a need for additional control is signaled to the prefrontal cortex. The dorsolateral and ventrolateral prefrontal cortices then resolve the conflict by exercising top-down modulation over subcortical systems that constitute the pain matrix, including the amygdala (fear), insula (disgust), and ventral anterior cingulate gyrus (suffering). Activation of the pain matrix produces proximate motivation for avoiding or extruding the bearer of the stigmatizing mark. The flow of mirror neuron information is then suppressed, and person-to-person social cognition fails to activate. Empathy for the stigmatized person is suspended. The stigmatized person is then behaviorally extruded and oppressed, for which the stigmatizer typically feels no guilt.

Different types of stigma can recruit different brain circuits and signaling pathways. Moral stigma, for examples, activates circuitry of ventromedial prefrontal cortex that is essential for generating social disgust. Patients with damage to the ventromedial prefrontal cortex lose their aversion to intimate contact with strangers, social deviants, or those bearing misfortunes, such as the poor or homeless, whereas their moral disgust remained intact for those who violated the dignity of others, as with unfairness, cheating, or betrayal.”

One can imagine the intrapsychic conflicts and corresponding neurobiological chaos that internalised stigma could lead to… Could that play a role in auditory verbal hallucinations?

Therapeutic strategies are detailed:

“Role plays are used to practice psychotherapeutic strategies for recovery from internalized stigma by discovering aspects of oneself that are unsullied, intact, and worthy, while mobilizing defiance of the stigmatizing inner gaze. In manageable steps, patients practice steps of recovery”

For a view on the importance of social aspects in the recovery process, this talk is worth a watch.

Positive disintegration – a path to the resolution of ‘psychosis’?

“Without passing through very difficult experiences and even something like psychoneurosis and neurosis we cannot understand human beings and we cannot realize our multidimensional and multilevel development toward higher and higher levels.”

Positive disintegration – a path to the resolution of ‘psychosis’?

“Suffering, aloneness, self-doubt, sadness, inner conflict; these are our feelings that we have not learned to live with, that we have failed to appreciate, that we reject as destructive and completely negative, but in fact they are symptoms of an expanding consciousness. Dr. Kazimierz Dabrowski has spent 45 years piecing together the complete picture of the growth of the human psyche from primitive integration at birth; the person with potential for development will experience growth as a loosening of the stable psychic structure accompanied by symptoms of psychoneuroses. Reality becomes multileveled, the choices between higher and lower realms of behavior occupy our thought and mark us as human. Dabrowski called this process positive disintegration, he declares that psychoneurosis is not an illness and he insists that development does not come through psychotherapy but that psychotherapy is automatic when the person is conscious of his development. To Dabrowski, real therapy is autopsychotherapy; it is the self being aware of the self through a long inner investigation; a mapping of the inner environment. There are no techniques to eliminate symptoms because the symptoms constitute the very psychic richness from which grow an increasing awareness of body, mind, humanity and cosmos… Without intense and painful introspection and reflection, development is unlikely. Psychoneurotic symptoms should be embraced and transformed into anxieties about human problems of an ever higher order. If psychoneuroses continue to be classified as mental illness, then perhaps it is a sickness better than health.” [1]

“Unless we change our thinking… our understanding of psychogenic emotional and psychosomatic disorders and their therapy  will  remain  superficial,  unsatisfactory, and incomplete. Psychiatry and psychology will be unable to genuinely comprehend the nature and origin of spirituality and appreciate the important role that it plays in the human psyche and in the universal scheme of things. These revisions are therefore essential for understanding the ritual, spiritual, and religious history of humanity,  shamanism, rites of passage, the ancient mysteries of death and rebirth, and the great religions of the world. Without these radical changes in our thinking, potentially healing and heuristically invaluable experiences (“spiritual emergencies”) will be misdiagnosed as psychotic and treated by suppressive medication.” [2]

The phases of recovery from psychosis are detailed here

Third-wave strategies for emotion regulation in early psychosis: a pilot study (2015)

Third-wave strategies for emotion regulation in early psychosis: a pilot study

Aim: Emerging evidence supports the priority of integrating emotion regulation strategies in cognitive behaviour therapy for early psychosis, which is a period of intense distress. Therefore, we developed a new treatment for emotional regulation combining third-wave strategies, namely compassion, acceptance, and mindfulness (CAM) for individuals with early psychosis. The purpose of this study was to examine the acceptability, feasibility and potential clinical utility of CAM.

Method: A non-randomized, non-controlled prospective follow-up study was conducted. Outpatients from the First Psychotic Episode Clinic in Montreal were offered CAM, which consisted of 8-week 60–75 min weekly group sessions. Measures of adherence to medication, symptoms, emotional regulation, distress, insight, social functioning and mindfulness were administered at baseline, post-treatment and at 3-month follow up. A short feedback interview was also conducted after the treatment.

Results: Of the 17 individuals who started CAM, 12 (70.6%) completed the therapy. Average class attendance was 77%. Post-treatment feedback indicated that participants found the intervention acceptable and helpful. Quantitative results suggest the intervention was feasible and associated with a large increase in emotional self-regulation, a decrease in psychological symptoms, especially anxiety, depression, and somatic concerns, and improvements in self-care.

Conclusion: Overall results support the acceptability, feasibility and potential clinical utility of the new developed treatment. A significant increase in emotional self-regulation and a decrease in affective symptoms were found. No significant changes were observed on measures of mindfulness, insight, distress and social functioning. Controlled research is warranted to validate the effectiveness of the new treatment.

“…participants reported large improvements in regulating negative emotions (specifically self-blaming, rumination, and catastrophizing), and moderate to large improvements on affective symptoms (specifically depression, anxiety, and somatic concerns).”

Automatic thoughts may mediate the relationship between self-compassion and affect:

“…self-compassion and self-esteem increased positive automatic thoughts and decreased trait anxiety, whereas only self-esteem increased life satisfaction and decreased depression directly. Positive automatic thoughts increased life satisfaction and decreased depression and trait anxiety, and positive automatic thoughts mediated the relationship between self-compassion and negative affect. These findings suggest that both positive and negative automatic thoughts mediate the relationship between self-compassion and affect” [1]

fMRI studies have shed some light on the compassionate brain:

“…Imaging results showed that Compassion, relative to both passive-viewing and Reappraisal increased activation in regions involved in affiliation, positive affect and reward processing including ventral striatum and medial OFC. This network was shown to be active prior to stimulus presentation, suggesting that the regulatory mechanism of Compassion is the stimulus-independent endogenous generation of positive affect.” [2]

Similarly, Mindfulness Meditation has been studied:

“…recent functional imaging studies have identified the putative neurofunctional signatures of the change in the perspective on the self brought about by Mindfulness Meditation (MM). In particular, it has been claimed that during MM states detachment from identification with a static sense of self associates with a diminished self-referential, narrative/autobiographical, processing paired with enhanced present-based, experiential processing of the self. In the brain, this has been shown to reflect in decreased activity in self-referential cortical midline structures (e.g., medial prefrontal cortex) and enhanced activity in lateral structures such as the insula and the somatosensory cortex associated more with momentary interoceptive and exteroceptive self-awareness” [3]

Mindfulness meditation may also improve self-control via altered reward processing:

“…experienced mindfulness meditators are able to attenuate reward prediction signals to valenced stimuli, which may be related to interoceptive processes encoded in the posterior insula.” [4]

Cognitively-Based Compassion Training uses analytical and didactic techniques to reorient one’s perspective on his or her relationship with others. It is through this active analytical process and reorientation that empathy and compassion are cultivated. The instruction unfolds in the following order:

1: Developing Attention and Stability of Mind

2: Cultivating Insight into the Nature of Mental Experience

3: Cultivating Self-Compassion

4: Developing Equanimity

5: Developing Appreciation and Gratitude for Others

6: Developing Affection and Empathy

7: Realising Wishing and Aspirational Compassion

8: Realising Active Compassion for Others

See more:

Recovery, not progressive deterioration, should be the expectation in schizophrenia (2015)

Recovery, not progressive deterioration, should be the expectation in schizophrenia

Since the time of Kraepelin, schizophrenia has been considered to be a progressive deteriorating illness. This perspective has been bolstered by a generation of studies demonstrating deficits in brain volumes on magnetic resonance imaging (MRI) scans and in performance on a broad range of cognitive tasks in individuals with schizophrenia.

Despite the introduction of effective pharmacological treatments and evidence-based psychosocial interventions, fewer than one in seven people affected are considered to meet criteria for recovery. The possibility that the pathophysiology of schizophrenia involves mechanisms that progress over the longitudinal course of the illness is often assumed to explain the poor outcomes observed. Advocates for early intervention have embraced this paradigm as it implies that early treatment has the potential to arrest a disease process that would otherwise continue on an unrelenting march to severe mental deterioration.

While progression of an active disease process would provide a compelling explanation for the poor outcomes so commonly observed, it is not consistent with what we have learned from modern studies of the longitudinal course of structural brain abnormalities, cognitive deficits and clinical outcomes associated with schizophrenia. Rather, schizophrenia appears to be associated with stability of these measures over the longer term. It is time to consider the possibility that clinical stability and recovery rather than progressive deterioration should be the expected outcomes from schizophrenia.

“How recovery from schizophrenia is envisioned is likely to vary greatly between individuals. Psychiatrists have typically embraced a “medical” model of recovery that emphasizes the elimination of symptoms and a return to normal levels of functioning; patients-consumers may find a “rehabilitation model of recovery” more compelling, with its emphasis on creating a meaningful and satisfying life in one’s community. Identifying those personal goals that are of most importance to each individual patient is critical, as outcomes that are not a personal priority are unlikely to be realized.

While there is room for debate about how recovery should be defined, it should be clear that most individuals with schizophrenia have the potential to achieve a stable remission of symptoms and substantial levels of satisfaction and happiness. Future outcome studies will need to incorporate outcomes that reflect the patient experience. Societal resources will also need to be allocated to support the realization of a broader patient-centered conception of recovery.”

‘Personal Paradigm Shifts’ and Recovery

In contrast to the extensive coverage of (putative) pathology in schizophrenia and therapeutic pharmacological interventions, little has been mentioned in regard to ‘recovery’ on this page.

The following provides a ‘map towards recovery’ which I will be consulting:

A multiple-case study exploring personal paradigm shifts throughout the psychotic process from onset to full recovery

The aim of the dissertation was to explore how the personal paradigms of those who have recovered from long-term psychosis changed throughout the psychotic process, from onset to full recovery. My hope was that such an inquiry might provide us with useful information regarding what takes place during the psychotic process at the most fundamental (existential) level of experience, and that perhaps this information might offer some guidelines and perhaps even a more or less universal map that can be of service to others who are still struggling with psychosis.

Qualitative multiple-case study methodology was used to inquire into the experience of six participants who had suffered from long-term psychosis and who are now considered to be fully recovered. Data collection consisted of an initial questionnaire, one live interview of a minimum of one hour, and three follow-up email interviews. A quantitative instrument was also used (the Posttraumatic Growth Inventory) to supplement the qualitative data. Data analysis consisted of developing individual and cross case themes for each of six prefigured categories of experience: description of the anomalous experiences, the onset and deepening of psychosis, recovery, lasting personal paradigm shifts, lasting benefits, and lasting harms. After exhaustive analysis of the data, a theoretical model was formulated that assisted in discussing the implications of the data.

The results revealed that all six participants had striking parallels in their experiences with regard to all six categories of experience. The most central implications that emerged from the findings with regard to all participants are as follows: an overwhelming existential threat to the self apparently played an important role in the onset of psychosis; the psychotic process was likely initiated by the psyche as an attempt to regain equilibrium in the face of this threat; recovery was primarily assisted by reconnecting with hope, meaning, a sense of agency, and the cultivation of healthy relationships; psychiatry generally caused significantly more harm than benefit in the process of recovery; and the successful resolution of the psychotic process apparently involved a profound reorganization of the self along with significantly more lasting benefits than harms.