What Research Have You Been Doing on Psychosis? An Interview with Staff Psychologist Dr. Jeremy Ridenour (Part 3 of 3)
Q: You’ve been writing about and researching psychosis – what are your interests and what have you discovered?
JR: My primary interest is trying to understand how to work with people with schizophrenia psychotherapeutically. There are medications, some of them efficacious, but about a quarter of people with schizophrenia have a limited response to medications, so other interventions are needed.
According to the literature, one of the factors that correlates with positive “community functioning” (a way of measuring outcome – how someone is engaging the world, how satisfied they are with their relationships or their work) – is not only focusing on symptom reduction (i.e., reducing the frequency of voices, minimizing paranoid ideas or delusional beliefs), but also on the ability of a person to develop improved social cognition.
Social cognition has been defined in broad ways, but simply put, it’s about how someone thinks about themselves and other people in relationships. A person’s ability to think in complex and nuanced ways about how they think and feel, about how others think and feel – that can be a very important intervention target for psychological/psychosocial treatment. People with better social cognitive abilities are better at evaluating both the explicit understanding and implicit understanding of interpersonal situations (e.g., reading the facial expression of others to infer their emotional states).
People with schizophrenia often have severe deficits in social cognition, which sometimes comes through in their symptoms. For example, paranoia can be viewed as a more simplistic way of understanding how another person’s mind works – tending to attribute malevolent intentions to someone in a rigid, inflexible manner. The reality is that people’s motivations are quite complex. One of the things I think we need to work on is developing interventions that specifically target social cognition to help people with schizophrenia develop a more complicated way of thinking about their mind and someone else’s mind.
Cognitive behavioral therapy (CBT) is a commonly suggested form of psychotherapy for psychosis. CBT for psychosis focuses on reducing information processing biases around irrational thinking. Social cognition approaches, I think, are broader and less focused on just the irrationality of someone’s thinking. There is a greater focus on how a person makes sense of the world – because if someone can’t make sense of their own mind or how other people’s minds work, it’s hard to have goals, it’s hard to pursue those goals, and it’s hard to develop a sense of agency that allows one to find their way forward in the world. The kinds of interventions for psychosis being developed and researched right now related to social cognition are particularly useful for psychotherapy, which focuses on how people think and their interpersonal context.
Another area of research I’m interested in has led me to work with a group in Indianapolis that has, over the past 15-20 years, developed a treatment called “Metacognitive and Reflective Insight Therapy” (MERIT), which is a manual-based model of psychotherapy designed for treating schizophrenia and psychosis. More recently, they have been running clinical trials and I’ve been participating in a research project that we’re going to write up this summer looking at the question: “Is there a meaningful pattern regarding when someone’s psychotic symptoms emerge in a psychotherapy session?” There are debates in psychiatry generally about whether psychosis is meaningless noise, brain dysfunction, or lack of brain connectivity, or is there any pattern to psychosis? What our research has shown us – and I think we know this clinically and intuitively – is that in fact there are patterns and meaning. Previous research has shown that when a person with psychosis experiences threats to their self-esteem, they might turn to grandiose delusions or other psychotic symptoms. Our research specifically looks at a treatment being conducted in the Midwest, working to develop a qualitative coding system to look at how the therapist’s way of engaging the patient might contribute to the emergence of psychotic symptoms or reduce the intensity of psychotic symptoms. We’re trying to understand “Are there meaningful patterns and what are the contexts under which people become symptomatic?” – because we tend to believe symptoms are meaningful. They are not just random noise; they occur in a certain emotional and social context.
- Couture, S. M., D.L. Penn, and D.L. Roberts, “The functional significance of social cognition in schizophrenia: A review,” Schizophrenia Bulletin 32, suppl 1 (2006): S44-S63. doi: 10.1093/schbul/sbl029.
- Green, M. F., W. P. Horan, and J. Lee, “Social cognition in schizophrenia,” Nature Reviews Neuroscience 16, no. 10 (2015): 620. doi: 10.1038/nrn4005.
- Leonhardt, B. L., M. Kukla, E. Belanger, K.A. Chaudoin-Patzoldt, K.D. Buck, K.S. Minor, J. L. Vohs, J. A. Hamm, and P. H. Lysaker, “Emergence of psychotic content in psychotherapy: An exploratory qualitative analysis of content, process, and therapist variables in a single case study.” Psychotherapy Research (2016): 1-17. doi: 10.1080/10503307.2016.1219421.