Cognitive Behavioural Perspectives on Mental Distress – finding meaning in distress experiences

Duration: 10.44 mins 

Speakers: 

Interviewer, Tracey Holley 

Professor Max Birchwood, Birmingham and Solihull Mental Health Trust and School of Psychology, the University of Birmingham 

And how does your perspective give meaning to people’s distress experiences, such as hearing voices? 

Well, I mean a lot of the people that we see in services are, by definition, very distressed by their experiences, they seek help and are trying to make sense of why they’ve developed this particular mental health problem.  So let’s just carry on with the example of voices, it’s rather interesting.  So if I was seeing someone with voices I’d be very interested in saying ‘well what is your relationship with this voice?’. Now voice hearing is not just a distressing experience. Of course it can be a distressing experience – not always – but nearly always people who hear voices will personify the voice. They will assign it a name or an identity and very often in services most people who hear voices will ascribe great power and authority to the voice and will also ascribe it a particular kind of motivation. Sometimes that is a malign motivation to do harm or otherwise to the individual, sometimes it’s of a benevolent intention. But the key thing very often in distress with voice hearers is, as it were, the power imbalance between you as a voice hearer and the identity and the purpose that you ascribe to the voice and that alone is highly linked to the development of distress.   So I should say that people often think it’s the frequency of the voices or how loud they are and even what they say creates a distress. Well research that we’ve done and others have done have shown that not to be so much the case.  So the frequency of the voices or the audibility, or even what they say sometimes, the important driver of distress is this power imbalance, the perception of the voice as omnipotent and powerful and omniscient, and the voice hearer as very subordinate and deserving of their subordinate position.  So there’s two aspects to that that are very important.  One is why is it that people develop this subordinate relationship to a voice that perhaps they’ve had for many years where they didn’t have kind of relationship? This goes back to your question about meaning, because this relationship with the voice is a social relationship. It’s a relationship like any other but it’s a particular kind of relationship where someone feels under the power and authority of something that’s very powerful and often malevolent. So the kind of things I would do with trying to make sense of someone’s distress is first of all to say ‘well why is it that you believe this voice to be so powerful and you to feel so powerless?’ and to work with the individual beliefs that people have about the voices and in particular what makes them feel so strongly that the voice is so powerful?  So the aim of therapy in that case is not to get rid of the voices, but is rather to try and help the individuals to reduce the distress that’s linked to them.  One dimension of that is trying to work with the beliefs about the voices. There’s another dimension, which is that the subordinate relationship people develop within this particular relationship between the voice hearer and the voice, research that we’ve done has shown that this subordinate relationship is seen in other social relationships as well. So if someone is feeling lacking in confidence, cowed and downtrodden by the voice, very often if you ask them about other social relationships you’ll see the same thing being played out in those relationships as well. And this is very important because what we can try and help with is to give meaning to this experience. The meaning that we give to them is to say ‘well look, this is a relationship and you’ve developed a kind of lack of confidence, lack of assertiveness perhaps in many social relationships, and this is affecting and making you quite distressed in this particular relationship with the voice’.  So the second therapeutic option and the second way of trying to make sense of it is to work with an individual’s sense of subordination and sense of inferiority to other people. That goes back to our opening part of our conversation where I was describing how individuals developmental experiences can give individuals a sense of lack of confidence and inferiority and loss of self-esteem. So I hope perhaps you can see the connection as to how that can influence the way in which people develop a sense of low self-esteem and inferiority in relation to this particular relationship.   So we can draw upon those person and social influences on someone’s development in how that is brought to bear in relation to the relationship with a voice and in relationship to other people. It provides, I hope, some meaning to that particular relationship and some interesting therapeutic options. Obviously distress is manifested in different ways and what also interests me is the way in which people can get distressed by the experience of receiving a label or receiving a diagnosis and its social consequences and this interests me a great deal. So we’ve been doing a lot of work over the last few years on how people internalise what I guess you’d call ‘stigma’ and its social consequences. Well, stigma, mental health problems are stigmatised in just about every society. Mental health problems are constructed in slightly different ways but there are very few societies and communities where mental health is not a stigmatised experience.  What we’ve been particularly interested in is how the experience of mental distress -  and being a psychologist I’m interested in what people believe about those experiences and how they appraise them – how that has consequences for the individual. So I’m particularly interested in depression in people who have a diagnosis of psychosis.  As you know, depression and particularly suicidal thinking is actually very common in people with psychosis.  Extraordinary rates of suicidal thinking and suicide in psychosis, particularly in young people.  Something like 10%. It’s quite a problem. It’s not terribly well understood. We’ve been particularly interested in how people’s reactions to, and internalisation of stigma, can lead them along that path and as I say as a psychologist I’m particularly interested in what people believe about certain events and how they appraise them, as we say, and its consequences.  So there’s three appraisals, three beliefs, that we believe are very important.  They are loss, shame and entrapment. So individuals can feel a sense of loss, that the experience of mental health problems has led them to lose their social position or their social role in society, and that may be an enforced loss of social role or something that the individual has engineered for themselves as a result of experiencing stigma.  Shame is kind of self-explanatory, it’s the kind of sense in which you can’t hold your head up high amongst your peers and look other people in the eye and feel confident and proud of what’s happening to you and that people can learn to rise above it. And also entrapment is very important.  People can feel entrapped in an illness and in experiences in relation to voices, as we were saying earlier, or some people can feel a sense of entrapment in a major mental illness like psychosis. For example, if people find themselves going back into hospital or being subject to the Mental Health Act perhaps more than they should do, this can convey and people internalise a sense of loss of control and feel trapped by an illness.  So these are the kinds of things, these appraisals of loss, shame and entrapment, are very important in the development of depression, as we were discussing at the beginning.  But these are key appraisals influencing – well, the key appraisals of major mental illness which are very strongly predictive of individuals developing depression and suicide as a result of psychosis.  So you asked me about meaning and the meaning that people ascribe to having a label of mental illness and a diagnosis is very, very important.  It’s very important in trying to help people understand why they’re reacting as they are, why they’ve become depressed or feeling that life has got no future for them. And so again as a psychologist I’ll be trying to work with those particular appraisals or beliefs. 

END OF RECORDING