Now published with Psychiatry Research, doi: 10.1016/j.psychres.2016.02.006
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RUNNING HEAD: EARLY RELATIONSHIPS AND PARANOIA
Early relationships and paranoia: Qualitative investigation of childhood experiences associated with the development of persecutory delusions
Joanne M. Dicksona, Jamie Barskyb, Peter Kindermana, David Kingc, Peter J.Taylora*
aInstitute of Psychology, Health & Society, University of Liverpool, United Kingdom, L69 3GB
b Tameside & Glossop CAMHS, Peninne Care NHS Foundation Trust, Springleigh Clinic, Stalybridge, United Kingdom, SK15 2AU
c Psychology Department, Mersey Care NHS Trust, Rathbone Hospital, Liverpool, United Kingdom , L13 4AW
*Corresponding Author
Dr Peter Taylor
University of Liverpool
Whelan Building
Brownlow Hill
Liverpool
L69 3GB
United Kingdom
Email:
Tel: +44-(0)151 794 5025
Fax: +44-(0)151 794 5537
Abstract
Research suggests a link between Persecutory Delusions (PDs) and early interpersonal difficulties. However, little research has explored the first-hand experience of navigating such adversities in those who later developed PDs. The current study reports on a qualitative investigation of the early interpersonal experiences and challenges faced by a sample of individuals who have recovered from PDs, using a semi-structured interview. A sample of seven individuals who have previously experienced PDs were recruited from two National Health Services (NHS) and an Early Intervention Psychosis service in England. Using an Interpretative Phenomenological Analytic (IPA) approach, the analysis identified three main themes (early experiences, impact of early experiences, coping with adversity). Early experiences captured early inconsistent and problematic relationships in childhood, and experiences of victimization. Exploring the impact of these early events revealed important roles for the participants’ inconsistent sense of self, their negative perception of others, and their disturbed social functioning and substance use. Coping with adversity revealed distinct forms of avoidant and proactive coping. The findings are consistent with models of PDs that emphasize the impact of early interpersonal experiences, and offer support for attachment and cognitive factors.
Keywords: Persecutory delusions; qualitative; interpersonal adversity; childhood experiences
Now published with Psychiatry Research, doi: 10.1016/j.psychres.2016.02.006
1
1. Introduction
Persecutory Delusions (PDs) are delusional beliefs involving themes of others wishing or planning harm against oneself. PDs appear to exist at the end of a continuum of paranoid belief within the general population and can understandably be associated with considerable distress for the individual (Freeman and Garety, 2004; Freeman et al., 2010). Interpersonal adversity is associated with a greater risk of psychosis in general (Arseneault et al., 2010; Varese et al., 2012). A number of cross-sectional, retrospective studies further suggest relationships between PDs and early trauma, abuse, neglect and victimisation/bullying (Ashcroft et al., 2012; Freeman and Fowler, 2008; Lopes, 2011; Shevlin et al., 2014; Sitko et al., 2014). Trauma symptomatology is common in those reporting delusions, and some suggest both psychosis and Post-Traumatic Stress Disorder may emerge from common psychological processes (Alsawy et al., 2015; Freeman et al., 2013). Paranoia following experiences such as assault appears common (Freeman et al., 2013). Qualitative research has been helpful in understanding PDs (e.g., Startup et al., 2014; Stopa et al., 2012). Campbell and Morrison (2007) undertook a broad qualitative investigation into the phenomenology of paranoia and PDs and reported a role of early adverse experiences. However, this study lacked a specific focus on how early interpersonal adversity contribute to the formation of PDs, and so provided limited detail in this area. Using an Interpretative Phenomenological Analysis (IPA), the current study aims to undertake an indepth qualitative investigation of the early interpersonal experiences of individuals who have held PDs.
A variety of mediators may account for this link between early interpersonal adversity and PDs. From an attachment theory perspective, Internal Working Models (IWMs) involving expectations about the self and others that have emerged through early caregiver relationships that are not appropriately attuned, sensitive or supportive (or which are disrupted by external adversities) may lead to PDs(Wickham et al., 2015). Attachment style mediated the relationship between early adversity and PD symptomsin a large community sample (Sitko et al., 2014). Similarly, others have found associations between PD symptoms and insecure attachment patterns (Gumley et al., 2014). Insecure IWMs may prime individuals’ towards expecting threat and hostility from others, which could underlie the formation of PDs.
Cognitive models suggest other potential mediators. Maladaptive beliefs or schema may emerge from trauma and lead to the development of PDs (Campbell & Morrison, 2007; Fowler et al., 2012; Freeman et al., 2013; Gracie et al., 2007). Fowler and colleagues (2012), for example, found that negative cognitions about the self and depressed mood, predicted PD symptoms over time in patients. Freeman and colleagues (2002) suggest that such beliefs may affect attempts to understand anomalous experiences, leading to delusional explanations. Defensive attributional processes, individuals may attribute negative ideas about the self to others, have also been suggested to lead to PDs (Bentall et al., 2001). It has been further suggested that different attributional styles may underlie two forms of paranoia, poor me (negative events externally attributed, persecution viewed as not deserved) and bad me (negative events internally attributed, persecution viewed as deserved; Melo et al., 2006). A tendency to Jump to conclusions is also a risk factor for psychosis though its specific link to delusions is weak (Dudley et al., in press).
The way in which individuals cope with interpersonal adversity may also be important, with more avoidant (e.g., suppressing thoughts or memories of events) coping being tied to a greater risk of PDs (Fisher et al., 2012; Freeman et al., 2013). Such avoidance may prevent the normal integration of trauma-related memories and so may maintain a sense of ongoing threat (Ehlers & Clark, 2000), which could drive PDs. Gumley and colleagues (2010) outline how coping strategies such as avoidance be part of underlying insecure attachmentpatterns. They suggest avoidant coping may lead to more negative reactions from others and enhance feelings of alienation from others (Gumley et al., 2010).Avoidance may also prevent the disconfirmation of maladaptive beliefs underlying PDs (Stopa et al., 2012).Defensive strategies such as submissiveness may also emerge from interpersonal threat. Memories of submission to others during childhood has been correlated with paranoia (Carvalho et al., 2015), but others have found that bullying was related to less submissiveness (Lopes, 2011).
An exhaustive review of potential mediators of the link between interpersonal adversity and PDs is beyond the scope of this paper. It is likely several mechanisms interact in formation of PDs.
It is unclear if individuals’ personal narratives of their early experiences, and the ways these impacted upon their psychosocial development, are consistent with the models outlined above. Such findings would be important in confirming or challenging these models. The current study therefore adopts a qualitative approach (IPA) using a homogeneous sample to examine, from a first-hand perspective, how early interpersonal adversityare seen to contribute to the development of PDs. A qualitative approach was adopted because it is unbounded by the choice of research tool and construct (unlike quantitative methods) and so allows the possibility of novel or unexpected findings. IPA was used as it provides an in-depth, idiographic understanding of processes and experiences and in particular enabled us to explore the meaning-making that occurred around participant’s experiences of adversity, which was central to our aim of understanding how these experiences linked to PDs. These methods have the capacity to both confirm and challenge quantitative findings, and extend them by giving us greater detail concerning what these experiences are like at the phenomenological level. The current project builds on the results of Campbell and Morrison (2007) by adopting greater focus on the link between interpersonal adversity and the formation of PDS.
IPA is influenced by phenomenological schools of thought, which stress the importance of understanding the lived experience of individuals and the individuals as active ‘meaning-makers’ (Smith and Osborne, 2008). This is particularly relevant to the current research which sought to explore how interpersonal events were interpreted by individuals, and then how these interpretations were meaningfully associated with the onset of their PDs.
2. Method
2.1. Participants
Participants were recruited from two National Health Service (NHS) community mental health teams and one early intervention psychosis service in Northern England. Potentially eligible individuals were initially approached by a member of their clinical team regarding the study, before being contacted by the researcher. Inclusion criteria were past experience of PDs (irrespective of diagnosis) and absenceofPDs for the preceding 8 months, as reported by their clinical team and established via the persecution and deservedness scale (Melo et al., 2009). Participants were asked to complete the measure with reference to the time when they were most distressed with endorsement of at least seven out of 10 items as “possibly true” or “certainly true” needed for inclusion. Forty potential participants were initially identified by clinicians from these sites. Of these, twenty-four people were deemed too unwell, did not wish to be contacted by the researcher or were unable to be reached when their clinicians attempted to make first contact with them, six did not attend screening appointment, and three were still actively paranoid. One female and six male participants, ranging in age from 18 to 43 years (M = 34 years), made up the final sample. Four participants had a chart diagnosis of Paranoid Schizophrenia and one of Delusional Disorder. Two participants had not received a formal diagnosis but were judged by their psychiatrist as experiencing a psychotic illness, with clear evidence of persecutory delusions.
2.2. Procedure
Each consenting participant attended one screening interview, to check eligibility via the PaDS. After the screening interview, a research interview was conducted individually with each participant.A semi-structured interview schedule was developed in collaboration with two consultant clinical psychologists with extensive experience of working with people with PDs and psychosis and a researcher with an expertise in IPA. The interviews were conducted by the second author (JB). The schedule provided a guide to the interviews and was used flexibly, so the researcher could follow each participant’s account to explore indepth the particular phenomenon under investigation. Thus, the order of questions and use of prompts varied. The interview then focussed on four areas: relationships, coping (with stress, symptoms, others), impact and content of delusions, and both past and present day experiences. All interviews were recorded and transcribed verbatim, and participants allocated an alias name.
2.3. Analytic procedures
Analytic procedures followed IPA guidelines (Smithand Osborn, 2008). The second author systematically analysed each individual transcript. Analysis involved identifying increasing levels of abstraction from initial codes, emerging themes, clustering emerging themes through to identifying super-ordinate themes across all participants. In keeping with IPA, emergent super-ordinate themes represent commonalities and variations within the data (Reid et al., 2005). A theme captures more succinctly and with a higher level of abstraction participants’ accounts. To ensure the validity and credibility of the analytic interpretations (Elliot et al., 1999; Yardley, 2008), several transcripts were reviewed with members of the research team. Further, a researcher with an expertise in IPA reviewed each transcript and each stage of the analytic procedure from initial coding through to the final written account.
2.4. Reflexivity
The analysis was primarily undertaken by a trainee clinical psychologist (now qualified) with support of a senior researcher in clinical psychology. The research teams understanding of psychosis at the outset was one that accommodated social and psychological factors alongside biological variables. Initially the research team had a leaning towards a cognitive understanding of psychosis and PDs, particularly the defensive attributional model (Bentall et al., 2001). Through the process of undertaking the study the research team moved towards a consideration of more relational and attachment-based understanding of PDs.
3. Results
Three ‘super-ordinate’ themes emerged from participants’ accounts, and each of these themes comprised subthemes, as presented in Table 1. Pseudonyms are used to maintain participant confidentiality.
TABLE 1 ABOUT HERE
3.1. Early Carer Experiences
Participants described in detail a range of early experiences. All identified difficulties in their early relationships with caregivers. Most discussed this in terms of a difficult or lacking relationship with their father, which was for some characterised by a harsh and unfair use of discipline:
I think he has always been a volatile character, because he drinks, so that leaves an impression on you if you’re young… (Tony).
I never kind of felt that close to him where I could speak to him about anything, erm because he was really strict when I was young… (Peter).
Two participants discussed a difficult relationship with both parents, while John alluded to his exposure to abuse before being removed from his parents’ care by social services:
You know, I can’t go into massive detail about it but I have been left a bit maladjusted by my upbringing, sexually you know, things that were a bit weird to say the least… (John).
Six of the participants referred to significant experiences of victimisation during their childhoods. For Tony, Peter, Alex and Dominic this was characterised by peer-bullying during secondary school:
The worst one was about five lads put me against a wall and kicking me in the shins for a good 10 minutes and that was pretty nasty (Tony).
I…got bullied…people…teased me about the shoes I was wearing and stuff like that… (Peter).
John reported a more pervasively hostile environment throughout his childhood, characterised by ongoing threat and victimisation from primary school through to college. Sarah on the other hand, reported a one off event, when she was fourteen, of being violently attacked by three close friends.
Participants recalled some positive recollections from childhood, indicating that despite the adverse experiences described above, for most of the participants childhood was associated with positive as well as negative experiences. Sarah spoke of her childhood as generally positive, including her experience of school and her relationship with her parents. Tony and Alex spoke positively of their time in junior school and of aspects of their early childhood in general. Even in the context of difficult or lacking relationships with caregivers, Sarah, Tony, Peter and Alex all experienced positive relationships with the other parental figure and, even in the context of its problems, Peter, was able to identify positive aspects to his relationship with his Father.
Early adverse experiences seemed to significantly shape participants’ adult lives and how they made sense of their present lives and mental well-being. Notably, the ability to recall early positive experiences and nurturing relationships, even in the face of past adversity and abusive experiences, was a crucial feature in defending or buffering against the deleterious effects of past aversive experiences. Whilst fathers were more often involved in adverse experiences, female caregivers could also be abusive or neglectful, and fathers could also be a source of positive memories. Hence, the interplay of adversity and positive experiences do not map simply onto specific caregiving roles.
3.2. Impact of Early Experiences
Some of the participants questioned the impact of their early relationships. In doing so, they demonstrated a propensity to make sense of their adult functioning in the context of their childhood experiences:
I don’t know what happened in those three years before my nan started bringing me up, so I don’t know how my development was affected in that way… (John, 125-128).
I never had a life of being channelled, and now I am an adult and I have to be responsible for myself…it’s more difficult for me…[it’s] not the language I was brought up with (Gary).
It was clear that experiences of victimization and difficulties in early relationships impacted on the participants’ sense of self. Peter described his problems with depression in school and his associated sense of feeling unloved, bad, and worthless. Dominic, Sarah, Tony and Peter had a sense that they were different in some way to other children, because of their sexuality, level of confidence, physical condition and financial situation, respectively. The adverse experiences that Tony and John endured made them think that something was fundamentally wrong with them:
[it] shaped my thoughts about me…on a self-esteem level it just really ground me down…[I thought] I was worthless and just there was something fundamentally wrong with me that I couldn’t cope… (Tony).
I just thought…something in my development had gone wrong…so I couldn’t relate to people naturally…I thought they would hate me if I just relaxed… (John).
Each of these participants linked their sense of being different, and their sense of vulnerability, to the difficult relationships they experienced with others. It was also apparent that most participants, despite their difficult contexts, were able to experience more positive self-concepts. For example, Peter harboured a sense that he was talented, knowledgeable and friendly, while Sarah’s childhood perception was that she was bubbly, outgoing and sociable before the onset of her problems in later life. Dominic seemed to hold a childhood perception that he was more clever and insightful than other children.
Therefore most participants experienced an inconsistent or fluctuating sense of self. This was further demonstrated by Tony, who discussed a distinction between his implicit and explicit self-esteem in secondary school:
I felt very powerful but really I wasn’t…the same underlying…feelings of worthlessness and er, of being a failure…definitely…would still have been there (Tony).
Tony’s account demonstrates how participants sought to hide or mask an underlying negative concept of self in order to cope. Further, participants’ early experiences shaped their perception of other people. The perception of an unfair world, and of powerful and unfair people, was prominent for several of the participants: