Understanding adaptation to first-episode psychosis: trauma and growth responses

It is generally accepted that psychosis is a traumatic experience that can lead to a shattering of ones beliefs about the self, others, and the world. First-episode psychosis (FEP) is an especially devastating experience as it usually occurs during adolescence and early adulthood, a crucial period in identity formation. To date, empirical investigations of the traumatic nature of psychosis have been confined largely to the impact of psychotic symptoms and negative treatment experiences as precipitants of a diagnosis of posttraumatic stress disorder (PTSD). However, understanding the traumatic nature of FEP need not be restricted to the experience of the acute episode but can be extended to adaptation to this experience during the recovery phase. Further, a comprehensive understanding of the traumatic nature of psychosis, especially FEP, needs to consider a broader trauma response which goes beyond the diagnosis of PTSD and incorporates potential positive outcomes. To extend understanding of the traumatic impact of FEP and individuals’ reactions to it, this research draws upon ideas of how people integrate and adapt to FEP. In clinical practice, recovery from FEP is predominately focused on restorative outcomes, which include ameliorating symptoms and replacing skill deficits. Yet, research suggests that recovery from psychosis is a dynamic and ongoing process in which people play an active role in. Authors have indicated that recovery from psychosis cannot be considered a return to prior health because the experience of psychosis has changed one’s life permanently (e.g., Oades et al., 2005; Davidson, 2003). Instead, it is argued that people can engage in a process of searching for meaning and purpose which can result in fundamental change (e.g., Reeves, 2000). This suggests that constructive as well as restorative processes are relevant to recovery from FEP. Posttraumatic growth is a concept postulated to capture positive outcomes from traumatic experiences that can parallel the pain and anguish trauma can cause. Growth goes beyond a return to prior level of functioning and involves a transformation which exceeds what was present beforehand (Tedeschi & Calhoun, 2004). Five domains of posttraumatic growth have been proposed: a greater appreciation of life and changed sense of priorities; warmer, more intimate relationships with others; a greater sense of personal strength; recognition of new possibilities or paths in life; and spiritual and existential development. This model is applied in the present research to provide a broader understanding of the traumatic impact of FEP and subsequent recovery. The current thesis aimed to explore how people understand the experience of FEP and its potentially distressing, restorative, and constructive outcomes. A pilot study was conducted first with two men and one woman who had experienced a first occurrence of psychosis. Results of interpretative phenomenological analysis (IPA) suggested further investigation was warranted of a broader model of the trauma associated with FEP and subsequent recovery. In the subsequent main study ten people with first-episode psychosis (3 women & 7 men) participated and clinicians were also interviewed as well a loved one of eight participants. IPA of data from in-depth interviews supported the proposal that recovery from FEP can be conceptualised within a trauma framework and constructive changes are crucial in understanding the impact of FEP and subsequent recovery and adaptation. In line with earlier research, the IPA data demonstrated the potentially traumatic nature of psychotic symptoms and negative treatment experiences. However unlike previous studies, this investigation highlighted that the traumatic nature of FEP is not contained to the acute episode and goes beyond the symptoms of PTSD to impact on one’s identity, relationships, and world view. The interviews also showed that people engage in managing their experience of FEP in a range of ways which can be both adaptive and maladaptive. Further, FEP can bring about positive transformation and these constructive changes can be perceived as an element of recovery. Comparative analysis of four case studies pointed to the importance of understanding various ways FEP can impact on the person and the nature of constructive changes in the context of individual’s explanatory model of FEP. The four case studies showed different levels of constructive processes and outcomes, which included both real and illusory constructive change. Interviews with loved ones showed the significant impact FEP can have on them, corroborating this broader view of the trauma response. The data were used to develop a temporal model of the recovery process which offers pathways for future research directed at expanding our understanding of the impact of FEP, subsequent recovery and adaptation. Applying this model will also assist to identify further avenues for facilitating clinical practice with FEP clients and their loved ones.