Rationale and aims of the study

Research has shown that there is an association between psychotic disorder and dissociation. However, the role that dissociation has within psychotic disorders is still unclear. To date there have been no qualitative studies exploring how these experiences are understood. From studies on experiences of voice hearing the benefits of qualitative exploration has been identified. The use of qualitative methodologies when exploring dissociation in psychotic disorders may support in gaining a better understanding of the role of dissociative experiences within the context of psychotic disorders and the meaning that individuals attribute to these experiences. The aim of the present study is to explore the lived experience of dissociation in individuals with a diagnosis of psychotic disorder. In particular, it will explore how participants subjectively experience and make sense of dissociation and their dissociative experiences.

It is hoped that, through gaining a deeper understanding of how individuals with a diagnosis of psychotic disorders experience dissociation, this may inform practitioner understanding of clients’ perspectives and experiences. This may also potentially provide indications regarding how to support such individuals as well as informing directions for future research in this area.

2.3. Method

2.3.1. Design

Taking into consideration the exploratory nature of the research aims, the present study used a qualitative methodology. A semi-structured interview was utilised to elicit participants’ accounts of their experiences. Since the principal aim of the study is to understand the lived experiences of dissociation in individuals with a diagnosis of psychotic disorders, Interpretative Phenomenological Analysis (IPA) was considered to be the most appropriate method of analysis. IPA is phenomenological as it aims to explore how individuals make sense of their world and the meaning that particular experiences hold for them (Pietkiewicz & Smith, 2014; Smith & Osborn, 2008), allowing for a greater understanding of the meaning that individuals bring to their experiences of dissociation within the context of psychosis. However, it is also important to recognise that the experiences individuals discuss are likely to be partial and complex accounts constructed by the participant and the researcher (Larkin, Watts, & Clifton, 2006). Therefore, it is important to hold in mind the researcher’s position and aim to provide an account which is as close to the individual’s experience as possible (Smith, Flowers, & Larkin, 2009).

2.3.2. Materials

A semi-structured interview schedule (Appendix D) was developed by the principal researcher and the research team who were familiar with working with individuals with a diagnosis of psychosis and qualitative research methods. The questions within the schedule were constructed based on the aims of the study, consideration of qualitative studies exploring experiences of psychosis and studies exploring voice hearing within the context of psychosis (Beavan, 2011; Dilks et al., 2010; Flanagan et al., 2012). In line with IPA epistemology, the interview schedule was designed to enable participants to

explore relevant experiences through non-directive, open-ended questions (Smith et al., 2009).

2.3.3. Procedure

2.3.3.1. Ethics

Ethical approval was obtained from Coventry University (Appendix E) and the British Psychological Society’s code of human research ethics was adhered to (The British Psychological Society, 2011). Written informed consent was sought using a participant information sheet (Appendix F) and a consent form (Appendix G) developed using guidance from the Health Research Authority (HRA) (Health Research Authority, 2014).

2.3.3.2. Recruitment

Participants were recruited through third sector support groups. The researcher approached third sector organisations regarding the study and received gatekeeper permission from managers of these organisations to advertise the study. The researcher provided a research summary sheet (Appendix H) of the study that was advertised within the organisations and the researcher also attended support groups to discuss details of the research study. Potential participants gave verbal consent to managers of organisations for the researcher to contact them to discuss the study in more detail.

Participants who were interested in the study were provided, by the researcher, with the participant information sheet (Appendix F) giving details about the purpose of the research, what participation in the study would involve and ethical issues. Recruitment criteria for the study were detailed in the participant information sheet and the researcher discussed these with each participant to ensure that they met those criteria. Participants were included if they were aged 18 years or older, had a diagnosis of a psychotic illness or disorder, self-identified as having experiences of dissociation and reported feeling able to hold a one to two hour long conversation in English.

Participants were excluded from the study if they were in an acute phase of psychosis, accessing acute inpatient care or accessing crisis support services. Participants were also excluded if their psychotic symptoms were a consequence of an organic condition such as Dementia, they had a diagnosis of bi-polar disorder, they had a diagnosis of substance induced or puerperal psychosis, or if they had a diagnosis of an at risk mental state.

2.3.3.3. Interviews

Semi-structured, individual interviews were conducted by the researcher between December 2015 and March 2016. Interviews took place at support group locations that were familiar and accessible for participants. Prior to the interview participants were requested to complete a written consent form and demographic information sheet (Appendix I). The interviews lasted between 30 and 100 minutes. The interviews were digitally recorded with consent from participants and they were informed that any identifying information would be removed from the verbatim transcripts. At the end of the interview participants were made aware of available support organisations (Appendix J) in case of any concerns or distress raised.

2.3.4. Participants

Five participants were recruited, including two males and three females. Their age ranged from 27 to 56. Four of the participants described themselves as white British and one as white African. All of the participants had a diagnosis of psychotic disorders including schizophrenia, paranoid schizophrenia, schizoaffective disorder and psychotic depression. None of the participants had a diagnosis of first episode psychosis and all of the participants have experienced psychosis for a number of years. Two of the participants were married and three were single. Two of the participants had children. Two participants lived with their partners and three participants lived with their parents. To preserve anonymity, participants were provided with pseudonyms.

2.3.5. Analysis

2.3.5.1. Procedure

Following each interview, the audio recordings were transcribed verbatim and any identifying information was removed. Participants where provided with a pseudonym. An excerpt of a transcript is included in the appendices (Appendix K). An IPA framework was used to analyse the data following steps outlined by Smith et al. (2009). Briefly, transcripts were read and re-read prior to initial coding. The transcript was read, initial codes and emerging themes were identified and these initial themes were developed into sub-ordinate themes and super-ordinate themes for one participant. This process was repeated for all participants prior to eliciting the patterns across all cases and clustering them into sub-ordinate themes within the super-ordinate theme. A more detailed description of the analysis process, together with figures, are included in the appendices (Appendix L).

2.3.5.2. Validity

Guidelines for qualitative research provide steps to ensure credibility (Thomas & Magilvy, 2011; Yardley, 2008). The process of coding and development of themes was reviewed by a colleague and discussed (Thomas & Magilvy, 2011). In addition, themes were discussed with the research team. An audit trail of the data analysis process and a reflective journal was kept by the researcher in order to assist with transparency, reflexivity and checking (Yardley, 2008). Prior to conducting interviews, the researcher engaged in a “bracketing interview” in order to highlight potential biases which were considered throughout the process of analysing the data.

2.3.5.3. The researcher’s position

IPA methodology highlights the importance of the researcher being aware of their own preconceptions and how these can impact upon interpretation and analysis of the data (Larkin et al., 2006; Smith et al., 2009). The researcher’s interest in the research study

stemmed from experiences of meeting individuals who have faced hardships in life but have overcome these without professional support to live fulfilling lives and the contrast of this to individuals who later in life experience profound mental health difficulties. The researcher was a trainee clinical psychologist with no prior involvement with the third sector voluntary organisations involved in the recruitment to the study or prior clinical experience working with individuals who have dissociative experiences. However, at the time of conducting the interviews the researcher worked in a service supporting individuals with psychotic disorders. This was a new experience for the researcher who had no previous clinical experiences of working with individuals with a diagnosis of psychosis. The researcher was therefore more aware of experiences of psychotic disorders which could have influenced the distinction between psychotic and dissociative experiences.

On the other hand, the researcher had an interest in the concept of dissociation and had knowledge of prior research in this area. This was acknowledged during analysis of the data and careful consideration was given to any experiences described by participants which the researcher believed to be a symptom of psychotic disorder or a dissociative experience. The researcher engaged in a “bracketing interview” prior to research interviews which identified that the researcher anticipated individuals not to have a clear understanding of their experiences and attributing some of their experiences to psychosis. The researcher also considered whether dissociation would be a separate experience from psychosis and anticipated that individuals would view these experiences as different but interlinked in some way. These views were taken into consideration during the process of analysis as there were times where these anticipations impacted on the grouping of initial themes into sub-ordinate themes.

2.4. Results

Following the analysis of the data, one super-ordinate theme emerged; Emotional impact of unsafe uncertainty. The theme and sub-ordinate themes are shown in table 2.1 and discussed narratively with consideration of convergence and divergence within themes.

Table 2.1: Super-ordinate and sub-ordinate themes

Super-ordinate theme Sub-ordinate themes