A recent study in Qualitative Research in Psychology seeks to expand our understanding of what it is like to experience a first crisis in psychosis. The authors use qualitative interviewing methods to understand the experience in its embodied and emotional elements, moving away from a strictly neurobiological disease model. The data is also considered for how it can inform responsible, effective treatment for individuals in crisis.
“A survivor discourse has emerged and has begun to challenge the ‘psychopathology’ of breakdown and crisis. First-person accounts of psychosis as well as phenomenologically-oriented and survivor research continue to support this shift towards recovery-oriented and person-centred practice and research in the field, which is echoed in a renewed acknowledgment of the importance of emotional experience after a period of neglect, where symptom-oriented pharmacological and cognitive-behavioral approaches to treatment were favored,” write Sarah Bögle and co-author Dr. Zoë Boden.
Although there is a long history of psychologists attempting to understand the experience of psychosis, modern researchers are still working on mapping its personal, thematic elements using in-depth descriptive interviewing methods. This can be linked to critical efforts in psychology and psychiatry to emphasize the whole human being, rather than focusing solely on the brain and neurochemical explanations.
“Over the past two decades and with the support of the service-user/survivor movement, social, emotional, and psychological recovery has also been recognized as important. New models of recovery have been developed, which define recovery as an individual and meaningful journey or process and take into account the complexities and many, subjective meanings of recovery,” write the authors.
The current study uses phenomenological interviewing methods to flesh out the lived experience of people undergoing first-time crises in psychosis. They aim to get at the “fullness” and “richness” of these “felt experiences.” They also seek to understand how these experiences might interact with issues of adaptation and recovery.
Peer support workers recruited seven participants through mental health charities, where they were involved in peer support groups. Semi-structured phenomenological interviewing methods are used, aiming to capture verbal, visual, and embodied aspects of the experience.
“Hermeneutic-phenomenological research aims to explore the ‘what is’ (noema) and ‘how it is experienced and understood’ (noesis), while embracing the intersubjective, embodied and embedded nature of human experience. Hermeneutic phenomenologists explicitly use interpretation to make sense of and situate their participants’ lived experiences within the context of their life situation, the broader cultural and historical context, as well the specifics of the research situation. Taking a hermeneutic-phenomenological approach, the researcher aims to ‘grasp at the meaning’ of the participants’ sense-making while remaining true to the participants’ experiences – as well as acknowledging and valuing the researcher’s involvement in the research process,” the authors explain.
The authors discovered three main themes in their data. The first theme they call feeling shattered, as expressed by the interviewee remark, “It was like a lightning bolt hitting my world.” This was defined by a shattered sense of self, a feeling of being trapped, and suicidal despair.
Several participants described this experience in terms of a sudden shock or attack and linked it to past experiences with traumatic abuse. A sense of “apocalypse” was common: pain, horror, being trapped, and a lack of power.
“ pushed about, bullied, emotionally, and physically abused […] It would stop, it would – it would stop all my normal functions. […] That’s when it [hearing voices] first started. It was a horrific experience,” one participant explains.
The second theme the authors call “an all-enveloping strangeness and lingering threat.” This theme was marked by “feelings of disorientation” and “a lingering sense of threat.” Confusion, being overwhelmed and feeling as though the world is alien or unreal were shared experiences. There was also a strong sense of being unable to distinguish what was “true” from what was “not true.”
This confusion coincided with fearful anticipation of danger. One participant described this as an “air of danger.” The experience of threat was often undefined and unknowable, more of a background feature of life than any nameable danger.
“Yes, it just felt like you’re being watched and perhaps people are following your every moves, so you have to be careful and very … I guess there’s also a feeling of … Like I was always a bit scared and frightened of everything that I encountered.”
The third theme was lacking a sense of belonging, expressed by one participant, “I was left stranded in the dark.” All seven participants reported this experience of loneliness and disconnection. The experience was often followed by a desire to avoid contact with other people, for the participants’ safety. Feelings of abandonment, such as by God, were also a reported experience. Participants longed for connection but struggled to feel safe enough to pursue it.
“I didn’t think I was part of it [the world], I didn’t think I was ever going to get better. I didn’t think anybody understood me, I felt alone, I wanted to achieve in the world, but didn’t think I ever would.”
Bögle and Boden note that trauma was a common feature in the experiences of their participants, confirming previous research linking trauma and psychosis. These historical traumatic experiences were present in the psychosis, often amplified as loss of sense of self, unreality, and sense of imminent danger. The authors suggest that trauma-informed perspectives can likely improve the wellbeing of individuals who have psychosis. They conclude:
“Services that consider the person holistically, taking account of how they view others, the world and themselves, which see ‘symptomatology’ as meaningful experience, and which consider the feelings and emotions of the service-user as something to be acknowledged and explored, rather than solely medicated, may also offer longer-term benefit by enabling people to feel safe enough to reconstruct their sense of self as a social being.”
Bögle, S., & Boden, Z. (2019). ‘It was like a lightning bolt hitting my world’: Feeling shattered in a first crisis in psychosis. Qualitative Research in Psychology, 1-28. (Link)