The rehabilitation treatment of patients with psychosis of the residential structure of the mental health operative unit of Torre Annunziata

Introduction

The recognition of emotions in others and in oneself is a delicate argument to confront four psychiatrists because often it refers to an ability to compromise And is the source of many difficulties. We define emotion as the subjective component of an affective sensation that goes together with and individual’s conduct. While in the past and in pre science psychology, emotion was considered a disordered factor in the behavior of rational man, Darwin introduced a significant and revolutionary opposing opinion:  emotions are an evolutionary mechanism that aids in the survival of a species that effects an individual in their environment. 

The traditional definition of emotional categories often refers to primary or basic emotions: fear, anger, happiness, sadness surprise or disgust. These emotions can often be traced to the original response characteristics. 

In the opinion of Eckman (1992), these emotions are innate and universal, characterized by a pattern of specific physiological activation. They are established quickly, and have an automatic mechanism to evaluate stimuli. 

Social and emotional withdrawal is a component commonly found in schizophrenia and depression as a manifestation of affective dulling.  An affective dulling and loss of logical connections are also in the same vicinity as the construct of alexithymia, the difficulty in identifying and communicating feelings, the problems in distinguishing between feelings and somatic sensations of emotional activation, an impoverished and restricted imaginative life, and a style of concrete and reality-oriented thinking. Alexithymia is considered a very important feature of affective dysregulation disorders, a prerequisite for the development of negative symptoms.

Project Aims

 The initial idea of a path to emotional literacy with residential  hospital patients was born after evidence emerged of a marked difficulty to recognize and express emotions by patients with psychotic  psychiatric pathologies. The professional team, made up of a psychiatrist, a psychologist and a psychiatric rehabilitation technician often met to compare notes on the need for an intervention that could be useful in counteracting the alexithymia that characterizes many guests and that can have an important impact on interpersonal relationships. The underlined objective is to evaluate, using the appropriate tools, the impact of a path of emotional literacy could have on these patients. The first element to be pursued  is maintaining commitments made by consistently participating in meetings. The path considers development one of the biggest emotional competencies, and the acquisition of generalized abilities for everyday life and in relationships with family and friends. 

Materials and Methods

The proposed work, lasting a year, consists of a weekly path with the structure’s residents, and is assessed at T0 and T1 using the TAS-20 (Toronto Alexitimia Scale) and ESCQ-45 (Emotional Skills & Competence Questionnaire). The topics covered range from the recognition of emotions based on facial expressions to the description and sharing of fears and desires, passing through the recognition of the parts of the body involved in an emotion; very important for these patients were the meetings dedicated to anger management and awareness of their own personal way of reacting to it.

Description of the sample of patients involved

The chosen sample for the path of emotional literacy consists of 10 users, of which 7 are men and 3 are woman,  homogenous in that they are all residents, and of the diagnosed pathology (psychosis), albeit with different types of comorbidities. Table 1.1 illustrates the main characteristics of the sample involved.  

Initials	Age	Gender	Schooling	Marital Status	Years of Illness
A.N.	49	M	8 years	unmarried	15
C.L.	49	M	8 years	unmarried	28
C.M.	42	M	13 years	unmarried	24
I.G.	60	M	13 years	unmarried	29
M.A.	53	F	8 years	married	20
M.D.	50	M	8 years	unmarried	27
M.J.	61	F	11 years	separated	23
P.G.	47	M	13 years	unmarried	17
V.A.	51	M	8 years	umarried	15
V.G.	51	F	10 years	Separated	21

The entire central team  worked together to choose these patients for the emotional literacy study. The selection criteria took into consideration each patient’s psychopathological compensation condition and their difficulty in recognizing and managing emotions, and as a result of this the patient’s need of a path that addresses these issues. In addition to this, the ability to support this work from start to finish without  suspensions and or a necessity to exit the project was also taken into consideration. Each patient deemed as a suitable recipient of the proposed work was then informed about the start of the path, the topics that would be covered, the timing and purpose of the project, and gave his or her consent to take part to his or her healthcare professional.

Analytical Evaluation Scale

The analytical evolution scale used to monitor the results of the emotional literacy study, which were administers at the beginning and end of this work, were the T.A.S. – 20 [1] (Toronto Alexitimia Scale – 20 Item) and the ESCQ – 45 [2] (Emotional Skills & Competence Questionnaire – 45 Item).   

The questionnaires were individually administered and filled out by the involved patients, but some requires help to fully understand some parts. All of the participants  gave answers consistent with what was then demonstrated by them during the course they took, and expressed the difficulty they felt  in recognizing and verbalizing their own and others’ emotions with varying intensity.

The Structure of the Eotional Literacy Intervention 

The emotional literacy course, which participants attended weekly in a space dedicated to rehabilitation groups from S.I.R. who hosted the participants, was created by a team that believed in the idea of gradual progress.  The topics covered and the tasks assigned were of increasing difficulty, starting from the definition of emotions necessary to be able to manage themselves and interpersonal relationships. The entire project lasted one year, and all the patients followed the project one meeting at a time with view absences and with growing interest as time passed, motivated by the possibility of using the new skills gained in everyday life. There were several moments where it was necessary to remind and encourage participants of their goals to keep the group homogeneous and avoid that temporary moments of personal crisis that could affect participation in the group and affect the continuity of the work carried out, but these moments overall  had a positive  effect and the group remained united from the beginning to the end of the proposed work. In the course of this year each participant continued to follow other project associated with S.I.R. and maintained individual psychological and psychiatric appointments, where it was possible to assist, monitor and support the emotional literacy project. 

 At the beginning of each meeting each participant was asked to fill out the following form to reflect on their current emotions and to verify that patients were more aware of their own emotions, and that adequate recognition of those emotions was gradually being acquired.

After filling out the sheet, each participant could choose to share their work with the group, and in so opening themselves up to the group, or to send them to the project operators without comment. This was also used as a way to note gradual changes in participants. 

Emotional Recognition  

After the first one on one meeting and administration of analytical evaluation scale, the course began with the identification of 6 primary emotions in order of complexity: happiness, sadness, dear, surprise, anger and disgust. Each of these emotions was described using facial images that express that emotion and the underline the physical characteristics of these emotions (open or closed lips, corners of the eyes turned up or down, eyebrows arched or raised etc..); below each face depicting the emotion the interventions of the patients  were reported regarding:

• what do I feel when I feel this emotion
• on what occasion do I feel this emotion
• when I feel this way

The 6 primary emotions along with the participants comments are used in the following sheets, filled out by each participant  as a way to report all the interventions, and then place them on a notice board for illustrative purposes; each participant, on the other hand, had a personal form where they could record their own responses. The sheets of each participant were then collected in a personal file, which later would attest to the progress and reactions of each participant in a clear and intuitive way. This first work was completed over an arch of meetings for each emotion described, each of them lasting about 60 minutes. Only the appropriate responses for identifying  emotions were reported in the general form, but it should be emphasized that not all interventions were congruous and that often a description of a state of mind or an experience did not match with the emotion under examination, demonstrating the initial confusion experienced by patients. The attempt put in place was therefore to bring order, reporting on the form the contributions deemed appropriate and at the end illustrating the result of the joint work: the description of the emotion and self-reflection on the personal moments their were the protagonist of.

Sadness and fear were the emotions that evoked the most immediate and numerous responses, some of them with disarming clarity; with other emotions, like disgust and surprise, the group experienced more difficulty and required a clearer guide. On the whole, useful schemes were obtained for framing each specific emotion,  which were also subsequently used to quickly review the notions learned and to add adequate content as the participants’ awareness of their emotions was increasing.

The results obtained are shown below.

We then worked by showing patients different faces and asking them to identify the emotion depicted so they could memorize each characteristic and expression. Other forms instead asked for emotions elicited by certain sentences; in this phase the participants worked on the sentences over several different meetings, using a profile of each of the 6 fundamental emotions. Form 1.8 is an example of this.

Particular attention was paid to the sentences referring to contexts that allowed the manifestation of multiple emotions at the same time (eg “I fought with my brother” ➜ anger / sadness), talking about them at length and underlining how it would be possible to use more than one emotion while handling a similar situation. The theme of emotional ambivalence was also introduced in this phase, and with this how it could happen that people might have contrasting emotions in the same situation, which was particularly hard for the participants. While the coexistence of two emotions at the same time, like anger and sadness or joy and wonder, was easy for participants to accept, not all participants were ready to accept the complexity of ambivalent emotions, which generally evoked amazement and disbelief. It was therefore decided to proceed step by step and return to the topic later.

Handling Anger 

Three meetings were dedicated to anger, to it’s definition and how to handle it, as was necessary as it was strongly felt in all the participants. Given this emotion was so complex and difficult to manage for the participants , these meetings also took place in the presence of the Service psychologist. 

After quickly repeating the expressions that characterize an angry face and speaking about what situations can result from this emotion, the participants were asked to remember particular moment in which they had been overcome by this emotion. They were able to think of an instance of anger with little difficulty, and sometimes felt the emotion resurface as they explained the situation to the group.  This created the opportunity to for them to describe their personal reactions to anger which was different for each of them, and an opportunity to think of way to better confront similar situation. Form 1.9 was proposed to identify emotions and mental states that hide behind anger which trigger and angry reaction.

In this way it was possible to identify two contrasting  behaviors in response to anger, described by patients in a clear way: an explosive reaction, expressed by fights, a short temper and breaking things, and a submissive reaction, characterized by closed oneself off, isolation and silence. From the description of these two reactions to anger, a rich discussion was born that went beyond simple handling of anger. It was difficult to make participants understand that there was another way to reaction besides their usual reactions, and most of all it was difficult to make the patients with “explosive” reactions understand the “submissive” reactions and vice versa, which was in line with definition of “anger” even if they don’t share common characteristics. 

From that point an alternative way to handle angry reactions was searched for, leading to a middle road between the two types of anger, which were divided into the following steps:

1. I try to calm down;
2. I speak to the person who made me angry;
3. I explain what made me angry and how this action made me feel;
4. I listen to his point of view and, if possible, try to clarify it; if not, I go away.

As result a conversation begun about each participants preferred way to calm down: listening to music, taking a walk, resting or speaking to someone about what had happened. Each of them expressed their personal preferences along with their personal difficulties, drawing inspiration from the suggestions introduced by others.

The implementation of the modeling by the psychiatric rehabilitation technician and the psychologist, and the role play by a couple of patients who self-applied to the experience, was very important in depicting the steps proposed above. This allowed the group to elaborate their own experiences regarding the meetings dedicated to anger management, and at the same time created a playful atmosphere that soothed the moods that the previous discussion had rekindled.

Each meeting regarding anger lasted about 90 minutes given that wealth of ideas expressed and the conversations and debates that grew from it. The entire group of participants were more involved and engaged, and reacted well to the proposed stimuli.

Emotional Nuances   

After having described and recognized the base emotions, the moment had arrived to broaden viewpoints  by exploring the horizon of the infinite emotional nuances that define the moods that everyone experience. In the same scope, each participant was asked to complete a form about the most common secondary emotions. The participants were asked to associate each secondary emotion with a situation or event, as they had done for the original 6 emotions.

Fig. 1.11 includes some secondary emotions with participant’s relative responses regarding each of them. The idea was inspired by the theme of contrasting emotions that can coexist in the same person or the same situation; each participant was asked to color a heart, filling it with different colors to represent different emotions to depict the emotions that characterized their mood at that precise moment. Fig. 1.12  shows M.d’s exemplary results., who was  one of the patients who had shown more difficulty in understanding the coexistence of conflicting emotions.

Other forms and exercises required participants to place secondary emotions in the right categories, recognizing the macro-areas they belong to and stimulating the identification of numerous nuances of daily experience.

Physical monitoring of emotions

Every emotions, be it positive or negative, has a personal physical positioning; you belly or the knees can avert us to fear, just as sadness can involve the heart or the head.  The work carried out in order to stimulate self-observation and recognition in the body part most affected by each emotion was very engaging for the group, who felt free and listened to their body in each way. Here there was no wrong answer, as the physical perception of emotions is subjective and extremely variable between people; the participants took part in this group with total autonomy. To express the physical aspect of emotions, an activity was created that involved cutting out, pasting and placing the chosen emotions along a large outline of the human body. Each participant took their own outline representing themselves, and cut out from numerous cards with the names of the emotions most felt in that moment; each name was then glued to the area of the body where the patient believed to have felt that emotion.

Physical monitoring of emotions created an occasion to, in a playful and dynamic way, pass time dedicated to self-observation and reasoning. From the outside, it was good to see the patients touching their heads, bellies, to see them put their  hands on their hearts and close their eyes, as a way to show their understood that they would find the emotion right there. Patient feedback on the proposed exercise was positive, and was confirmed by the precision with which most of the templates were “filled in “.

In some cases, the participants asked for clarification about the meaning of certain terms, but never tried to “copy” the placement of the cards on the template from one another. Once the task was completed, the comparison regarding the results obtained was complete and not without food for thought both for participants and for us operators.

Fig. 1.13 shows the outline built by C.M., in which the choice of exclusively negative emotions and the placement of the word “angry” on the foot stands out; M. was one of the patients who showed, in fact, an “explosive” reaction to anger while working on conflict management.

Anxious stimuli

A meeting was dedicated to reflection on the situations that represent the main sources of anxiety for many patients in the group, the most common comorbidity among the participants. Anxiety often leads to avoidance, implemented by many patients in a massive and generalized way, as can be seen in form 1.14, compiled by P.G. It strongly represents his state of being and the isolation that this condition induced in him. The form requires participants to assign a number from 1 to 10 to the various situations or places proposed, where number 10 is representative of the situation most avoided and the number 1, least feared.

By filling out this form, apparently simple and easy to understand, rich discussion between the patients involved was stimulated, which allowed the opportunity to address ideas not previously addressed within the group. Some were surprised by the answers given by fellow participants, trying to convince the others that they shouldn’t fear certain situations; others felt relief in confronting the group about their problems, as if this could be a way to warn the other about situations in which they would not want to be involved.

The purpose of the meeting was certainly not to solve the problems presented, but rather to stimulate the group’s participants to open up to the other, to share and confront each other.

Fear 

Another noteworthy meeting dedicated to fears and the strategies implemented to deal with them. Here too, the discussion was rich and stimulating, where an ever greater openness on the part of patients as palpable as the path of emotional literacy progressed.

Introduced by form 1.15, which depicted some of the most common fears with their most tangible solutions, the topic was then addressed by each participant in the group individually, drawing their fear and writing something about it. The discussion expanded with the personal contribution of each participant about the moments in which the fear in question was experienced, and the ways to cope without reaching a personal limit. The origins of each fear and how they arose was also discussed.

Fig. 1.16 represents the work carried out by I.G. .

Patients had revealed themselves to be, at this stage of the journey, already more mature and aware of their moods; confrontations  were more fluid,  uncertainty and confusion were less, and all were now dedicated to the proposed work with greater willingness. The commitment made during the journey is evident and we noticed the habit of getting together in groups and talking about something that unites them, of dealing with issues in a more natural way. They  started to accept experiences that are different from their own and perhaps with conflicting ones as well.

The game

To encourage socialization, natural connections and personal openness between participants and operators, games and other expressive activities with an emotional theme were introduced to the group.

Fig. 1.17 shows a brief description of C.L.’s mood after he had spent the night with tachycardia, and of P.G., who shares his sadness. This exercise includes the recognition of the emotion you are experiencing, the representation of the face that characterizes it, the description of what you feel and the physical monitoring of the chosen emotion.

As a result, a real card game was created using the emotion cards shown in sheet 1.18; the game consisted of cutting out the cards, shuffling them by placing them in a pile to be turned over on the table, and taking turns drawing a card from the deck. Depending on the emotion that each participant drew, they would then have to stage it by mimicking their face or depicting an event that would evoke that emotion. This game proved to be both useful and fun, and was very much appreciated by the group; the operators also took part in it, contributing both to a modeling action and to the creation of a playful group atmosphere, in which getting involved would not have involved any kind of judgment. Some patients at first preferred not to take part in the game, remaining as observers, but all of them then gradually entered during the game  or participated in the meetings proposed later, on different days. At the end of the course, everyone in the group caught at least one emotion, even the most introverted like P.G. .

Card 1.19 instead shows an expressive activity in which patients were asked to write down the prevailing emotion at the time of the exercise, draw something related to it and assign it a music or a song, to be listened to all together during the execution of the drawing. The use of music was often proposed along the way, and it helped emotions to come out, to take shape, and to be shared without the need to be verbally described.

M.D., in the card shown, started with the choice of music (Ludwig Van Beethoven’s Symphony No. 5) and linked the composer’s drawing and the emotion aroused,

sadness. Before the end of the meeting, D. then added a cartoon that clarified the choice completed work: “When I was little I listened to Beethoven’s symphonies and even my father Filippo cried”. A memory, a piece of music, an emotion and a drawing.

Results and Conclusions 

Table 1.1 shows the results obtained by individual patients at T0 and T1 according to TAS-20.

The ESCQ-45 scale, on the other hand, shows a marked improvement in V.G., who shows a difference of 32 points between T0 and T1, and so is the user who has obtained the greatest increase in emotional and social skills.

With reference to the partial results obtained from the subscales, the “expression and recognition of emotions” subscale was the one recorded in V.G. the greatest improvement (T0 = 15, T1 = 22).

On the other hand, the one who recorded the lowest score increase with the ESCQ-45 was I.G., in accordance with the results obtained by the same patient at the TAS-20.

Also from the analysis of the results obtained with the compilation of the ESCQ-45 it appears that all patients have reported improvements as a result of the emotional literacy process, to a greater or lesser extent. The analysis of the subscales also shows a correlation between the items of the TAS-20 and those of the ESCQ-45: a high score in the “difficulty in identifying feelings” subscale of the TAS-20, for example, is often combined with a low score in the ESCQ-45 “expression and recognition of emotions” subscale.

In addition to improving their emotional skills, the group of patients involved in the emotional literacy path has shown, in my opinion, to be more aware of their skills as well as their shortcomings. It happened, for example, that some items of the evaluation scales that at T0 indicated a sufficiently high competence, recorded a “worse” score at T1 not for a lack of results, but for a greater awareness of the meaning of each request and of the personal limits of each one.

The participant who most has been shown to have achieved improvements in the recognition, identification and knowledge of emotions, as well as in the ability to “look inside”, was C.L., as evidenced by the results of the TAS-20. The music therapy  course certainly supported the result achieved, visible to the naked eye and very important for the path that the patient is carrying out in S.I.R. . C.L.  followed the entire process assiduously, with a great motivation for change, and with a personal and cultural background that allowed him to carry out an effective job. To date, he is more attentive to the state of mind of others, more aware of his emotions and better able to manage them adequately.

The patient who instead reported the least evident results was V.A. who,  already of an outgoing and self-confident character, has not always managed to participate in a relevant manner in the meetings held. At the end of the course the patient seems to report a greater theoretical knowledge about emotions, but the personal involvement expected and experienced by others is still far away.

All the participants were involved, at the end of the course, in a restitution meeting in which they  discussed results obtained  together and their perception of their own path within the group. Most of the patients reported the feeling of greater openness to one  another, while almost all observed an increase in the ability to self-observe and recognize their emotions.

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Notes

• [1] Taylor G.J., Bagby R.M., Parker J.D.A., Toronto Alexithymia Scale, 1992
• [2] Takšić V., Mohoric T., Duran M., Emotional Skills & Competence Questionnaire, 2001
• [3] Di Pietro M., L’ABC delle mie emozioni, Erickson, 2015.