Psychological Interventions in Early Onset Psychosis

Manchester Mental Health & Social Care Trust 1

Aims & Objectives

     Aims – To introduce the principles of psychological interventions for people with early onset psychosis Objectives – To provide an introduction to: Family interventions Coping strategy enhancement Motivational interviewing Early warning signs and action planning Cognitive behavioural therapy 2

Group Exercise

Divide into small groups The task of each group is to list as many ‘talking therapies’ as they can, discussing the usefulness of each therapy for people with psychosis Feed back to whole group for discussion 3

Psychological Interventions An Overview

Psychological interventions are an essential part of treatment options for both relapse prevention and symptom reduction Most of the current evidence base is for cognitive-behavioural interventions (CBT) and family interventions (FI) (NICE 2002) 4

Cognitive-behavioural Interventions(CBT)

CBT should be offered to clients with psychosis who have ‘persistent’ symptoms(NICE 2002). It also assists in the development of insight CBT encourages people to make links between thoughts, feelings and behaviours and helps to re-evaluate perceptions, beliefs and reasoning about targeted symptoms 5

Cognitive-behavioural Interventions(CBT)

CBT depends on an effective therapeutic alliance between clinician and client Several research studies have now investigated the efficacy of these approaches (e.g. Sensky et al 2000, Tarrier et al 1998, Kuipers et al 1997) 6

Cognitive-behavioural Interventions

A collaborative approach ensures the client is at the centre of care and is an active participant in decisions about treatment.

This enhances engagement with services. Structured and clearly defined sessions help to make time spent with clients as useful as possible 7

The Provision of CBT by Professionals

Most mental health professionals can effectively apply the principles of CBT, although there are some professionals who have more advanced training as specialists. Ongoing supervision is also necessary to ensure safety and effectiveness 8

Family Interventions

FI should be available to families who are living with someone with psychosis or who are in close contact with them(NICE 2002) High levels of ‘expressed emotion’ (EE) within a family has been shown to be an effective predictor of relapse in schizophrenia.

High EE is harmful when it is associated with critical and hostile comments and emotional over-involvement towards the person with psychosis 9

Family Interventions

FI can improve symptoms and reduce the chances of another acute episode FI use psycho-education and problem solving to help families cope managing the illness more effectively, deal with crises, reduce levels of distress, improve communication and provide support and education for the family (Barrowclough and Tarrier 1992) 10

Coping Strategy Enhancement (CSE)

CSE encourages clients to collaboratively review their present coping skills in managing distressing experiences.

Coping skills that work effectively can then be developed and enhanced. Those coping strategies that are less effective can be modified or abandoned.

This therapy is more ‘behavioural’ than ‘cognitive’ but has proved to be successful in clinical trials (Tarrier et al 1993; Tarrier et al 1998) 11

Motivational Interviewing (MI)

MI was originally developed as a treatment for drug and alcohol addiction (Miller and Rollnick 1991; Rollnick and Miller 1995). It is now used with clients with psychosis to enhance conmpliance with medication (Kemp et al 1996) and for those clients with a ‘dual diagnosis’ of drug and alcohol use and psychosis (Haddock et al 2002).

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Motivational Interviewing (MI)

MI is based on the theory of the ‘stages of change’ (Prochaska and DiClemente 1982). It is especially effective when clients are at either the ‘pre-contemplation’ or ‘contemplation’ stages. 13

Early Warning Signs & Relapse Prevention

Relapse rates in psychosis are extremely high – even if people stay on medication, up to 81% of patients relapse within 5 years (Robinson et al 1999) A number of studies have investigated the possibility of delaying, preventing or altering the course of relapse (Herz & Melville 1980; Birchwood et al 1989) 14

Early Warning Signs & Relapse Prevention

Birchwood et al (1989) designed an Early Signs Questionnaire which encourages the development of a detailed ‘time-line’ to clearly explore the pattern of events and changes in thoughts, feelings and behaviours that lead up to an episode of psychosis.

Working closely with the client and their closest carers, a list of early signs can be developed. This can lead to an action plan to help to spot relapse.

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Early Warning Signs & Relapse Prevention

Once the early warning signs list has been collaboratively identified, a detailed action plan can be negotiated.

This usually includes the following areas –  What the client and family should do if signs of relapse are spotted   What services agree to do to respond to the client’s and family’s concerns A DETAILED list of all resources etc – extra medication, phone numbers to call in a crisis 16

Early Warning Signs & Relapse Prevention

This work can be hard, especially when previous crises are reviewed in detail, as lots of bad memories and difficult feelings can be revisited.

This approach is very empowering for clients and families. At its best it enhances the relationship between them and services, gives them much more control over their treatment and enables them to feel supported in practical ways.

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Psychological Therapy Conclusions

There is a huge interest in providing psychological treatments to people with psychosis and the evidence base is growing.

If people with early onset psychosis are given this treatment, outcomes can improve One study has shown that using CBT can even prevent or delay the development of psychotic symptoms (Morrison et al 2004) 18