This interdisciplinary doctoral thesis represents the weaving together of several partially independent strands of research conducted by the author between 2008 and 2011 in the field of madness, work and recovery. The purpose of the thesis is, to borrow from Freud, to ‘work through’ some of the rich and diverse links between work and mental health as they appear throughout time and space, and in particular in a climate where getting people with mental health problems back to work is a central political priority. The first stream of the thesis is dedicated largely to an historical and philosophical analysis of the relation between work and madness, and especially the therapeutics of work. Next, voices from contemporary mental health service-users—drawn both from ethnographic work in spaces of ‘sheltered’ employment and narrative research with individuals in mainstream paid employment—are introduced to offer a series of disruptions to common understandings of what it means to be mad at work. Finally, the thesis turns to policy and to an examination of the ‘what works’ agenda in getting people with mental health difficulties back into paid employment. Rather than add further to this evidence base, the thesis seeks instead to describe what may be lost when ‘what works’ becomes the only way of thinking about recovery. Recurring themes in the thesis include the tensions between therapeutic work and damaging work; between curing madness and embracing it; between the complex relations between work, employment and activity and their role in recovery; and between the competing epistemological positions of service-user centred perspectives and critical hermeneutics in understanding the relation between work and mental distress. At their simplest, conclusions point to the need for a rich and plural theoretical landscape of work and mental health and to the need to resist overarching and inflexible policy interventions.

Background. Research has shown spontaneous imagery to be a common form of cognition in a chronic pain population. Imagery rescripting was found to be an easy and effective intervention in improving the pain experience, but similar to the immediate effects of distraction. The current study aimed to test the effects of imagery rescripting against an imagery distraction task through an online questionnaire. Method. Adults (n=126) were recruited through Internet pain support forums. An experimental design compared the immediate effects of intervention (imagery rescripting) vs. control (imagining a dream house) using Visual Analogue Scales of pain intensity, distress, physical threat and emotional threat (pain experience variables). A 4-6 week follow-up questionnaire used a repeated measures design to compare changes against baseline for pain experience variables and a measure of fear-avoidance beliefs. 106 participants met criteria for statistical analysis. Results. Both imagery rescripting and imagery distraction resulted in immediate and statistically significant improvements across all pain experience variables, to a clinically significant level. Further significant reductions were observed at follow up in fear-avoidance beliefs and levels of pain, distress and emotional threat (n=40). Conclusions. Imagery techniques are an effective way to improve the experience of chronic pain in the short term. The reductions observed at follow-up were small and may not have been due to the effects of imagery rescripting, as some participants also performed the imagery-distraction task. However, wider theoretical considerations point towards imagery rescripting as a useful therapeutic tool in chronic pain management.

This study explored the genetic influence of susceptibility genes on brain volumes in psychosis. More specifically, I explored whether certain allelic variations are associated with global brain volumes in subjects with psychosis, their relatives and in healthy controls. To increase the statistical power, I combined three different MRI scan datasets since a calibration study showed high intra-class correlations (ICC above 0.9) between MRI protocols (Chapter 3). I therefore included 535 participants (225 patients with psychosis, 130 relatives and 180 healthy volunteers). In the first analysis I compared grey, white and whole brain volumes between patients and healthy controls (Chapter 5). Patients with schizophrenia spectrum psychoses showed smaller grey matter and larger white matter volume, and smaller whole brain volume than healthy controls. They also showed smaller grey matter volume than patients with bipolar disorder, who also had smaller white matter volume than healthy controls. In the second analysis, I estimated differences in brain volumes between relatives and patients and healthy controls (Chapter 6). Only patients with bipolar disorder showed smaller whole brain volume than their relatives. There were no significant differences in brain volumes between the relatives of patients with bipolar disorder or schizophrenia and the healthy volunteers. Finally, I evaluated the role of familiarity on these volumes (Chapter 6). In families with schizophrenia the family clusters accounted for 48% of the total variance in grey matter volume, for 27% of the total variance in white matter volume, and for 35% of the total variance in whole brain volume. In families with bipolar disorder the family clusters accounted for 48% of the total variance in grey matter volume, for 43% of the variance in white matter volume, and 22% of the total variance in whole brain volume. In the second part of the thesis I explored genetic influence of 20 SNPs previously reported to influence brain morphometry in psychosis and in healthy individuals, on these volumes (Chapter 7). I found evidence for an association between OLIG2_rs762178, MCPH_rs930557 and DTNBP1_rs1047631 and grey, white or whole brain volumes. However, this association did not survive multiple comparison corrections. In conclusion, despite strong evidence of high heritability and familial influence on volumetric measures, I found not evidence of association between the selected candidate genes and these brain regions. These findings highlight the need to use large sample sizes when conducting this type of studies.

Background: People with serious mental illness (SMI, including schizophrenia and bipolar disorder) experience adverse health and premature mortality. Higher incidence and/or worse outcome of acute myocardial infarction (AMI) may partly underlie this. Objectives: To investigate the relative risk of AMI in adult patients with SMI. To compare receipt of invasive coronary intervention, inpatient mortality, and recurrence of cardiovascular diseases following AMI between patients with and without SMI. To investigate the association between AMI and recent antipsychotic exposure among people with SMI. Design: Historic cohort study for the first two objectives and a case-crossover design for the third objective. Setting: The Taiwan National Health Insurance Research Database (NHIRD). Participants: For the first two objectives, adult patients with diagnoses of schizophrenia or bipolar disorder were compared to general population controls. For the third objective, a ‘case-crossover design’ was utilized, with antipsychotic exposures compared between a ‘case period’ (proximal to the index AMI) and a ‘control period’ (more distal to the index AMI). Main Outcome Measures: Adjusted hazard ratios of AMI were calculated using Cox regression. Invasive coronary interventions and outcomes were compared in logistic regression models. Odds of antipsychotic exposure in case and control time periods were compared within individuals using conditional logistic regression models. Results: Overall, no increased risk of AMI was found in people with SMI, apart from in sub-group analyses (suggesting an excess SMI-associated risk in younger women). Patients with schizophrenia and bipolar disorder were less likely to receive invasive coronary interventions following AMI episode compared to controls, and inpatient mortality was higher in patients with schizophrenia compared to controls. AMI was significantly associated with more recent antipsychotic exposure in schizophrenia but not in bipolar disorder. Conclusion: Schizophrenia and bipolar disorder were only associated with raised risk of AMI in young women, but post-AMI care was less adequate in both conditions. A short-term risk of AMI following antipsychotic exposure in schizophrenia was suggested.

Background: Delusions are characterised by conviction, distress, preoccupation, and disruption. ’Jumping-to-conclusions’ (JTC) and a lack of belief flexibility (BF) have been shown to be associated with delusions. -- The thesis: The overall aim was to investigate psychological processes of change in delusions over time and to examine response to treatment of aspects of delusional experience. Specific questions were: do psychological processes associated with delusions change? And do reasoning biases predict change in delusions? -- Method: Three longitudinal studies were conducted using three separate samples of patients with delusions of at least moderate severity. Studies 1 (N = 40) and 3 (N = 16) involved patients in an acute phase of psychosis, whereas Study 2 participants (N = 273) were in the recovery phase. Study 1 investigated changes in delusional dimensions, JTC and BF over eight weeks of antipsychotic treatment. Study 2 examined the factor structure and longitudinal relationship of conviction, JTC and BF over 12 months. Study 3 assessed moment-by-moment levels of delusional dimensions, BF and aberrant salience over two weeks using experience sampling methodology. -- Results: During the early phase of antipsychotic treatment, all delusional dimensions improved over eight weeks (Study 1), whereas only distress and disruption improved over two weeks (Study 3). BF and conviction were distinct factors (Study 2), and higher flexibility was consistently related to lower conviction. JTC was stable within the study periods, although higher rates of JTC during the acute phase suggest improvement across phases. JTC predisposed to the presence of delusions (Study 2) and was associated with higher and more variable conviction during treatment (Study 3). -- Conclusions: That JTC and BF contribute to the development and maintenance of delusions was largely confirmed using longitudinal data.

Introduction: Nightmares are a common problem recognised in Post-traumatic stress disorder (PTSD; Neylan et al., 1998) and Borderline personality disorder (Semiz, Basoglu, Ebrinc and Cetin (2008)). In a healthy student sample, nightmare distress was positively correlated with paranoia and psychoticism (Levin & Fireman, 2002). However, nightmares have never been investigated in people with psychosis. Imagery Rehearsal (IR) has been effective in reducing the frequency of nightmares, improving sleep and symptoms of PTSD (Casement & Swanson, 2012), but again, has never been trialled in psychosis. Aims: Study A examined the prevalence of nightmares in those with psychosis, their link with sleep quality, psychotic, affective and cognitive symptoms. Study B investigated whether an IR protocol (IR; Nappi, Drummond, Thorp & McQuaid, 2010) might be suitably adapted for people with psychosis. Methods: Forty participants with psychotic symptoms completed a semi-structured interview to assess nightmares, sleep quality, severity of delusions, hallucinations, depression, anxiety, stress, global distress, PTSD, daily activities and working memory. Five participants completed 4-6 sessions of IR for nightmares (study B). Results: 55% of patients reported weekly distressing nightmares. Nightmare frequency was related to sleep quality, sleep efficiency and depression. More distressing nightmares were associated with worse delusions, depression, anxiety, stress and working memory. The case series demonstrated the feasibility of IR for the treatment of nightmares in those with psychosis; reductions in nightmare distress, vividness, intensity, affective and psychotic symptomatology were observed post-intervention. Conclusion: Nightmares are common in those with psychosis and impact on day and night time experiences. They may present a target for intervention. The cross sectional nature of study A and small, uncontrolled sample of study B present limitations to conclusions. Future research should aim to uncover the direction of causality between nightmares and daytime symptoms and further investigate IR as a nightmare specific intervention.

Introduction: Depression can be a very debilitating condition and can take a persistent course. Mindfulness-based interventions (MBI) have shown benefits for reducing risk of relapse and current depression. However, despite a strong body of evidence, there are currently few studies that have investigated the relative efficacy of MBI compared with an active control intervention. Moreover, little is known about purported mechanisms of action in MBI. The present study aimed to examine the effects of a brief mindfulness intervention as compared to a relaxation intervention in a sample of depressed patients. In addition, the study aimed to investigate which psychological variables contribute to changes in symptoms and mood. Method: Forty depressed patients (DPs) were recruited from the waiting list of IAPT services. Twenty participants were randomly allocated to a mindfulness intervention and 20 to a relaxation intervention. Participants (n= 40) attended two face-to-face assessments one week apart (active treatment phase), and had a follow-up one week later (n= 37) (follow-up phase). Participants were taught the intervention (mindfulness or relaxation) in the first assessment and were asked to practise it daily over the following week. Depressive symptoms, cognitive functioning, and emotion regulation were assessed at pre, post-intervention and follow-up. Results: From pre to post-intervention, self-reported symptoms of depression significantly decreased, cognitive functioning and emotion regulation significantly increased, changes were maintained at follow-up, but no differences between the two groups were found. Decentering and mindfulness were significant predictors of changes in depressive symptoms during the active and follow-up phases of treatment, respectively. Discussion: Both mindfulness and relaxation interventions reduced depression and enhanced cognitive functioning, which points to common elements between the two interventions. Decentering and mindfulness were common predictors of change. The findings have clear clinical implications, but also raise challenges regarding selecting a suitable active comparison treatment for mindfulness research.

Up to one third of patients with schizophrenia show only limited response to dopamine blocking antipsychotic medication. This could be due to distinct neurobiological abnormalities in this subgroup of patients. While there is robust evidence to suggest that the neurobiology of schizophrenia involves increased presynaptic striatal dopaminergic elevation, little is known as to whether this abnormality is present in treatment resistance, and consequently the relationship between this dopamine abnormality and the lack of response to treatment remains unknown. Furthermore, it remains unclear whether treatment resistance manifests at the outset of illness, and perhaps has a neurodevelopmental origin, or whether it evolves over time, possibly as a result of a neurodegenerative process. The first study in this thesis investigated striatal presynaptic dopamine synthesis in twelve treatment resistant schizophrenic patients, twelve patients with schizophrenia who had responded to antipsychotics, and twelve healthy volunteers, using [18F]-DOPA Positron Emission Tomography (PET). Thus, it was possible to test the hypothesis that the response to treatment is determined by differences in presynaptic dopamine function. The results demonstrated that there were no significant differences in striatal dopamine synthesis capacity between treatment resistant patients and healthy volunteers, whilst dopamine synthesis capacity was significantly increased in responders relative to treatment resistant patients. The difference was most marked in the associative and the limbic striatal subdivisions. A second, large follow-up study of first episode psychosis (FEP) patients, examined the course of treatment resistance over the 10 year follow up. It was found that over 80% of treatment resistant patients were persistently resistant from the initiation of antipsychotic treatment. My PET study, due to its cross sectional design, could not determine whether the normal dopamine levels predate the antipsychotic exposure in treatment resistant patients. However, by demonstrating that a great majority of treatment resistant patients are resistant to dopamine blocking antipsychotics at first ever initiation of treatment, my second study raises the possibility that these patients may have had normal dopamine levels even at the outset of their psychotic illness. In the same FEP cohort it was possible to investigate neurodevelopmental predictors of treatment resistance. The finding that the negative symptom dimension and younger age of onset were significant predictors of treatment resistance is compatible with the view that TRS may be of neurodevelopmental origin. Overall, my observations in this thesis indicate that TRS may be a distinct and enduring subtype of schizophrenic illness of a possible neurodevelopmental origin whose pathophysiology is not marked by alterations in dopamine synthesis capacity. Findings emerging from this thesis provide a platform for future studies, which may lead to the discovery of much needed new treatments for this disabling and intractable condition.

There is now considerable evidence showing pathology congruent cognitive biases in the interpretation of emotionally ambiguous information. Such biases selectively prioritise the processing of information that can confirm a pathological belief and thereby play a direct role in maintaining associated pathology. Although interpretation biases are well documented in the affective disorders, little work has been done in other psychopathologies, including psychosis. This thesis reports five studies investigating the degree to which pathology congruent interpretation biases are present in paranoia and paranoid psychosis. Chapter 1 introduces the literature on biased cognition in paranoia and paranoid psychosis. Chapter 2 (Experiment 1, n = 70) provides an evidence base for the interpretation biases relevant to paranoid thinking and identifies their level of content specificity in the non-clinical population. Chapter 3 (Experiment 2, n = 70) investigates the hierarchy and severity of paranoid thinking in the non-clinical population. Chapter 4 (Experiment 3, n = 90) validates the most sensitive measures of interpretation and reasoning biases in a clinical sample characterised by paranoid and non-paranoid psychosis. Chapter 5 (Experiment 4, n = 138) tests the prediction of interpretation biases on paranoid thinking and anomalous perceptions. Chapter 6 (Experiment 5, n = 60) tests the effectiveness of a novel ‘Cognitive Bias Modification’ for psychosis programme for use in the reduction of paranoid interpretations. Chapter 7 discusses findings in the context of the wider literature and in relation to existing cognitive models of psychosis. Results from this thesis demonstrate evidence that paranoid and valenced interpretation biases are associated with higher levels of trait paranoia. Individuals with higher levels of trait paranoia are also shown to make less non-paranoid interpretations of emotionally ambiguous information than individuals with lower levels of trait paranoia. Interpretation is an underlying cognitive process that, when biased in a paranoid direction, has the potential to contribute toward maintaining a paranoid psychotic state.

This study is situated in live supervision groups held over a two year period in a London training institute that delivers systemic therapy training. It focuses on the development of supervisory style which can be both consistent with a characteristic approach regardless of context as well as emerging and responsive to supervisees’ needs. The study includes data from twelve interviews with supervisors and supervisees plus one observation. Supervisors show a strong connection with their articulated characteristic style which distinguishes them from one another and provides an overarching frame of reference for both supervisory interventions and relationships with their groups. They demonstrate some consistency relating to the supervisory requirement to educate, develop systemic practice skills or the family facing work influenced by their considerable practice expertise. There are also some marked differences that appear to be linked to individual style and relational responses to their supervisees which captures the recursive influence of supervisees on supervisory style. The study found two main themes significant to both supervisors and supervisees, namely the development of technical ability through skill acquisition and the creation of connected relationships. Supervisory interventions that contribute to technical ability are shown through the educational function of supervision. The meaning made around these practices is much more complex and varied and significantly affects supervisory relationships. These relational constructions go on to define the relationships between supervisors and supervisees and impact learning. Connected relationship building in supervision is not new. This study offers a range of ideas to show the construction and effect of relationship building through the exploration of supervisory interventions, supervisory style, and responsiveness to supervisees, attention to professional standards and other factors such as gender and professional experience. These factors contribute to the development of relationships as well as the definition of relationships from the vantage points of supervisors and supervisees. Some tentative suggestions are offered to enhance the quality of supervisory relationships and thus improve learning. The study makes no claims that this is reflective of other live supervision experiences within the systemic field or indeed other disciplines that utilize live supervision methods.