Summary of the impact

This case study details the impact of Professor Matthew Ratcliffe's research on existential feeling in psychiatric illness. The impact is as follows:

(i) The research is influencing the practice of psychiatrists, clinical psychologists and psychotherapists in several countries, by enhancing understanding of patients' experiences and thus informing clinician-patient interaction, and also by featuring in clinical teaching and training.

(ii) It is having a significant influence upon research conducted by the mental health charity SANE, which in turn informs the charity's practice. It has also strengthened links between the charity's research and support services, and directly influenced the practice of front-line staff.

(iii) It helps those affected by psychiatric illness to understand and articulate their experiences.

Underpinning research

The underpinning research on `existential feeling' was carried out by Ratcliffe (appointed at Durham 1 October 2002), who introduced the term in a 2005 article, to refer to a variable sense of reality and belonging that shapes all human experience and thought. Changes in existential feeling, which are commonplace in everyday life and often occur in more extreme forms in psychiatric illness, are seldom articulated in terms of familiar moods and emotions. Instead, Ratcliffe notes, people speak of `feelings' of unreality, heightened reality, strangeness, unfamiliarity, existence, isolation, oneness with things, and so on. He maintains that such feelings are distinctive in virtue of two characteristics. First, they amount to an all-enveloping way of `finding oneself in a world', rather than a more specifically focused experience or judgment. Second, they are `feelings', in the sense that they cannot be extricated from bodily awareness. In his 2008 book, Feelings of Being, Ratcliffe builds upon this characterisation and offers a detailed analysis of existential feeling, which provides a means to convey, distinguish and further investigate a range of elusive but profound experiential disturbances that are central to many kinds of psychiatric illness. Since then, he has further developed the analysis in 25 articles and book chapters. In the process, he has reconceptualised various phenomena that are usually construed in terms of less encompassing changes in perception and/or belief, and also challenged tendencies to separate cognition from affect.

Since 2008, the research has focused upon the role of existential feeling in experiences of depression. According to the World Health Organisation, depression will be the world's leading cause of disability by 2020, with enormous personal, social and economic costs. However, psychiatrists and others have undertaken surprisingly little research on what it is like to be depressed, even though (a) most of the established diagnostic criteria for depression are implicitly or explicitly phenomenological, and (b) sufferers often complain that an inability to convey the experience to others adds to their suffering. Ratcliffe argues that the elusiveness of the experience is largely symptomatic of the fact that depression, in some cases at least, involves a radical shift in existential feeling — something that is seldom articulated or understood in the course of everyday life or, indeed, in psychiatry. Furthermore, labels such as `major depression' fail to distinguish importantly different forms of experience, adding to the problem. Ratcliffe has published detailed analyses of several aspects of depression, including despair, guilt, altered temporal experience, a sense of inability, belief that recovery is impossible, complaints of `living in a different world', and bodily symptoms. The research also involved a detailed, philosophically-informed questionnaire study on experiences of depression, which generated a substantial body of first-person testimony (see section 4).

References to the research

Outputs: Publications on existential feeling in psychiatric illness include:

Research Quality: The research includes a peer-reviewed monograph with Oxford University Press, which received very positive reviews. One reviewer describes Feelings of Being as "radically significant" (PsycCRITIQUES 54/16, 2009). Another remarks that "by radically problematizing the meaning of reality in this way, Ratcliffe's book helps to show why it is that some of the most interesting current work in phenomenology has connections with psychiatry" (Philosophy in Review XXX/2, 2010). The research also includes numerous articles in reputable peer-reviewed journals and edited volumes.

Research Grants: The research has been supported by two grants:

• AHRC Research Network Grant of £48,123 for the project `Emotions and Feelings in psychiatric Illness' (1 October 2008 to 30 September 2011).

• AHRC research grant of £294,000 for the project `Emotional Experience in Depression: A Philosophical Study' (1 October 2009 to 30 September 2012). Principal Investigator Ratcliffe. This grant was awarded through an AHRC-DFG (German Research Foundation) joint scheme, and the project involved close collaboration with a group headed by Professor Achim Stephan (University of Osnabrück, Germany).

Details of the impact

The impact has arisen progressively over several years, through increasing interaction and collaboration with beneficiaries. Principal beneficiaries are (1) clinicians (mostly psychiatrists, clinical psychologists and psychotherapists); (2) the mental health charity SANE; and (3) mental health service users.

Clinicians: Since 2005, Ratcliffe's published research has received increasing attention from clinicians, which has led to correspondence, speaking invitations and several collaborations. These have shaped the direction of the research, generating additional publications and further interactions with clinicians. At a 2005 conference (`Phenomenology and Psychiatry for the 21<sup>st</sup> Century', Maudsley Hospital, London), Ratcliffe introduced the concept of `existential feeling' to an audience of approximately 300 psychiatrists, clinical psychologists and others. He has since given over 40 conference or seminar presentations on existential feeling in 10 countries, most of which involved clinicians. For example, his 2011 lecture at the Tavistock Clinic, London, was attended by over 100 people, mostly clinicians. Two AHRC projects associated with the research involved eleven conferences or workshops. Speakers included sixteen prominent psychiatrists and clinical psychologists, most of whom participated in more than one event.

The resulting impact consists in a better understanding of experiences that are central to many forms of psychiatric illness but generally neglected or misunderstood. This improved understanding has led to changes in practice. Research findings have assisted clinicians by (a) challenging the view that certain phenomena are to be understood in terms of localised perceptual experiences and / or beliefs, (b) analysing an aspect of experience that many clinicians recognise but struggle to describe and explain, and (c) clarifying the similarities and differences between certain forms of experience that occur in psychiatric illness. Prominent psychiatrists, psychologists and therapists in several countries have described how the research has enriched their thinking, informed their interactions with patients and been integrated into clinical training. For example, the research has influenced the practice of the Consultant Forensic Psychotherapist at Broadmoor High Security Psychiatric Hospital, UK. She frequently encounters kinds of experience that are very difficult to understand, which reflect the distinctive predicaments of patients with psychiatric illness diagnoses who also face the prospect of indefinite detention. The relationship between her practice and Ratcliffe's research was explored through correspondence between them, which followed one of his conference presentations. This culminated in a workshop on `Ways of Being in Time' (Durham, July 2013), which they organised together. The impact of such interactions upon practice consists in a more refined ability to interpret distress, which contributes to therapeutic response. In her words, the research "helps clinicians like me reassess the lived experience of time in circumstances that are associated with high rates of depression and suicidality [...] The particularly important impact of this is that it helps clinicians maintain a more human and humane approach to care of those who are detained for years at a time; and helps develop the compassionate stance [...] This work deepens my clinical relationships with patients so we can provide better care".

Given the research's potential to enhance empathetic understanding and thus shape clinician- patient interaction, it is widely used in clinical teaching and training. For instance, a senior clinician at Massachusetts General Hospital and Harvard Medical School, USA, uses the research in clinical training as well as in his own practice. He reports that it "enhances therapists' capacities to understand psychological phenomena and be with clients". Hence it is used in "professional development seminars, training both interns and experienced clinicians". He adds that the research has had a "significant impact" upon his own practice, "enhancing" the "ability to be empathetically attuned with clients and facilitate their capacity for change". At Mount Holyoke College, also in Massachusetts, a Professor of Psychology has similarly reported that the research is having a "significant impact on the training of psychology students [...] especially those likely to practice as clinicians"; it has "enabled them to understand the complexities of depression far more deeply than [they] otherwise could have done". The research also features heavily in doctoral programmes in clinical psychology and social work at Rutgers University, USA, aimed at clinicians and senior mid- career social workers. Because of this, Ratcliffe was invited to teach three modules at Rutgers to approximately thirty students taking the social work course, and he did so in April 2013. In follow- up exercises, students were instructed by the course leaders to reinterpret clinical cases in the light of Ratcliffe's findings. In Colombia, the research has been disseminated through the Colombian Association of Psychiatry, influencing clinical practice and training. For instance, a psychiatrist based at Universidad del Rosario, Bogota, uses "the concept of existential feeling in case studies" in order to train "residents of psychiatry". In the UK too, the research has, to quote a prominent psychiatrist, "provided valuable training resources for clinicians". He uses it on clinical training schemes in London and the West Midlands, as it allows trainees "to appreciate the pervasive and diffuse nature of moods that chimes with the experiences patients relate to us" and to realize that "subjectivity and meaning remain important and crucial to clinical work".

SANE: Due to interest generated by the AHRC and DFG-funded project on depression, in 2008 Ratcliffe was approached for advice by the mental health charity SANE. This led to a continuing collaboration with SANE, and Ratcliffe is now a research advisor for the charity. Central to SANE's work is the provision of support for people suffering from psychiatric illness, largely through empathetic listening. `Front-line' staff members, consisting of approximately 140 trained volunteers, perform this role through a helpline, email and an on-line support forum. Ratcliffe's publications on existential feeling serve as an interpretative framework to help articulate otherwise elusive aspects of experience that are central to many service users' distress. This has contributed to the research of SANE's psychosocial research team on suicide, which itself feeds into the practice of front-line staff by facilitating greater understanding of service users' experiences and thus better support for them. Members of the SANE research team have benefited from their attendance of four AHRC/DFG project conferences in the UK and Germany. Also central to the collaboration were three 2012 meetings involving Ratcliffe, staff from the Durham Philosophy Department and Centre for Medical Humanities, and employees of the charity. During the first two meetings, the Durham group gave the SANE research team a substantial body of first-person testimony on experiences of depression (145 detailed questionnaire responses), and discussed its potential implications for the practice of the charity's front-line staff. The third meeting was a focus group that included the charity's research team, Head of Services and several front-line staff. In addition to this, the conception of clinical empathy that Ratcliffe's research embodies is now helping the psychosocial research team to provide an interpretation of the "SANE ethos" that underlies service delivery. Under the direction of the Head of Services, this is being used to assist with fundraising, develop training for volunteers, and rewrite some of the "Services" section on the charity's website.

The research has therefore assisted the charity by (1) providing direction and support for the SANE research team, which in turn feeds into practice (e.g. by disseminating their research to colleagues, producing leaflets, and through formal and informal conversations), (2) engaging directly with some of SANE's front-line staff so as to enhance their understanding of service users' experiences, (3) strengthening links between the charity's research and practice, and (4) helping to articulate the charity's aims.

Service Users: Many of Ratcliffe's presentations on existential feeling and/or depression have been attended by mental health service users, and by others who have been directly or indirectly affected by psychiatric illness. His published research is also read by service users, and this has led to sustained correspondence in some cases. Ratcliffe has received several unsolicited communications from people with psychiatric diagnoses, stating that the research serves to aid both self-understanding and the ability to communicate psychiatric distress. Some respondents to the depression questionnaire study also commented on the helpfulness of the research, expressing relief that somebody was acknowledging the aspects of experience they found most troubling. This kind of impact is exemplified by the effect of the research upon a well-known service-user, who has published accounts of his experiences and also produces a journal. He informed Ratcliffe that "Feelings of Being was an important book for me to read as it validated my lifelong struggle with derealization. I became aware that I had been indeed laboring under a severe handicap, which no one else had articulated. I shared the ideas of the book with other long time activists in National Alliance on Mental Illness". Because of the research's significance for those who are directly or indirectly affected by psychiatric illness, Ratcliffe was invited to give the keynote lecture at the June 2013 NHS conference `Survivors of Bereavement by Suicide'. The event was attended by over 100 people, including bereaved relatives, mental health service users and healthcare professionals. Its principal aim was to raise awareness of depression and suicide, and facilitate understanding. Ratcliffe's presentation, `The World of Depression' (an electronic version of which was also made available to participants after the event) played a central role in realising this aim. It had a direct impact upon those who were present, by informing their thinking about psychiatric illness and their various responses to it. The organisers reported a "huge amount of positive feedback from delegates, who gained a tremendous amount" from the presentation and subsequent discussions, which they found "fascinating and thought provoking".

Sources to corroborate the impact

1. The website of the project `Emotional Experience in Depression: a Philosophical Study' includes details of all project events (including names of clinicians and charity employees who participated) and details of the questionnaire study: http://philosophyofdepression.wordpress.com/
2. The website of the AHRC-funded project `Emotions and Feelings in Psychiatric Illness' includes details of two workshops and a conference, with the names of several clinicians who gave papers:
   http://www.dur.ac.uk/psychology/research/efpi/
3. A senior clinician at Broadmoor High Security Psychiatric Hospital has confirmed the impact of the research findings upon her practice.
4. A senior clinician based at Harvard Medical School and Massachusetts General Hospital has provided testimony regarding the research's impact on clinical practice and training.
5. A Professor of Clinical Psychology at Rutgers University has confirmed the contributions made by the research to teaching and training in social work and clinical psychology at Rutgers.
6. Ratcliffe is named as a research advisor on the mental health charity SANE's website:
   http://www.sane.org.uk/how_you_can_help/suicide_prevention/advisory_group/
7. The manager of the psychosocial research team at SANE provided testimony concerning Ratcliffe's work with the charity and can supply additional information, if required.
8. The Assistant Director of Clinical Governance (NHS Foundation Trust for Gloucestershire) has confirmed Ratcliffe's contribution to the 2013 Survivors of Bereavement by Suicide Conference and commented on its reception.