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Evidence-Based Reviews


5-minute first aid for psychosis

Defuse crises, help patients solve problems with brief cognitive therapy

Vol. 4, No. 1 / January 2005

Adding just 5 to 10 minutes of psychotherapy to medication monitoring visits can help patients overcome hallucinations, delusions, and other psychotic symptoms. Targeted cognitive-behavioral therapy (CBT) can:

  • prevent crisis visits and hospitalizations
  • improve long-term medication and treatment adherence
  • enhance the therapeutic alliance.

Treatment goals for patients with chronic mental illness are changing as clinicians, patients, and families aspire for more than improved symptoms ( Box ). 1-14 This article describes brief interventions to target medication nonadherence and positive and negative symptoms in patients with schizophrenia, schizoaffective disorder, bipolar disorder, major depressive disorder, and other chronic disorders.

CASE: VOICES FROM THE PAST

Ms. W, age 45, is seen every 6 to 8 weeks in an outpatient medication management clinic for symptoms of schizoaffective disorder, depressed type; posttraumatic stress disorder; and generalized anxiety disorder. She has a history of severe abuse by her father, self-mutilation in response to anxiety and stress, and repeated hospitalizations following visits to her mother.

She recently visited her mother again and saw her father as well. The trip led to increased symptoms of intrusive traumatic memories, thoughts of suicide with plans to overdose, visual hallucinations of her father, and increased auditory hallucinations with derogatory content.

Goals of the first therapy session after Ms. W’s trip home were to reduce her suicidal thoughts and prevent hospitalization. We encouraged her to list her positive qualities, accomplishments, important relationships, religious beliefs, goals, and dreams. She then wrote all these reasons to live on a cue card. Reading the card twice in the session stopped her suicidal thoughts, and she expressed some hope.

We encouraged her to read the card whenever suicidal ideas became strong. We scheduled her next visit 1 week later, and she contracted not to attempt suicide during that time.

DEVELOPING AN ALLIANCE

To develop an alliance with psychotic patients such as Ms. W, the first task is to help them leave each session feeling understood, validated, and enjoying the therapist’s company. This alone provides a powerful counterbalance to the isolation, demoralization, and hopelessness they bring to therapy.

Box

Why drug therapy alone is not enough

Pharmacologic and psychosocial interventions are changing treatment goals for patients with serious mental illness from improved symptoms to functional recovery, improved quality of life, and reintegration into the community. 1,2 Patients, families and clinicians increasingly view self-determination, independence, and recovery as realistic treatment goals. 3,4

Medication limits. Drugs are crucial to managing psychotic symptoms but inadequate for achieving recovery:

  • many patients with positive psychotic symptoms respond only partially or not at all 5
  • functional improvement does not always follow symptomatic improvement 6
  • medication nonadherence remains high, leading to repeated relapses. 7

Dual-therapy benefits. A combination of antipsychotics and psychotherapy has been found to increase the chances of recovery in schizophrenia. 8 Psychotherapy is also highly valued by patients and their families:

  • In patient satisfaction studies, 72% to 90% of participants with psychotic disorders said individual psychotherapy improved their lives. 9,10
  • In a survey of 3,099 National Alliance for the Mentally Ill family members, 88% rated psychotherapy as having some (53%) or considerable (35%) value. 11

Access problems. Despite psychotherapy’s benefits, access is extremely limited. In one survey, only 7.3% of patients with nonaffective psychosis received at least “minimally adequate” care (four or more medication visits that did not include psychotherapy). 12 Incorporating therapeutic techniques into medication monitoring clinics is one way to improve access to therapy for patients with serious mental illnesses.

Keep it brief. Psychotherapy in medication clinics differs from traditional models’ 15- to 45-minute sessions. 13 Patients with psychotic illness prefer brief interventions; a study of 212 patients found that 85% of those with schizophrenia preferred sessions:

  • less often than once a week
  • that focus on solving practical problems. 14

Table 1

5 steps in effective cognitive-behavioral interventions

  1. Identify the problem the patient wants to work on and narrow it down
  2. Rate the identified symptom or issue, where possible using a simple 0 to 10 rating scale
  3. Choose and use an intervention
  4. Rate the target symptom again, and get patient feedback
  5. Ask patient to write down what is learned on a card or in a notebook, and give patient an assignment to reinforce learning at home

Four principles for dealing with psychosis are normalization, universality, collaborative therapeutic alliance, and focusing on the patient’s life goals:

In normalization, the stress vulnerability model is used to explain psychosis to the patient. Psychotic symptoms are emphasized as something normal people can experience in extreme situations, such as:

  • hallucinations in states of sleep deprivation or medical and drug-induced states
  • paranoia as error in thinking in states of heightened vigilance and perceived threat. 15

Universality is the understanding that many people have experiences similar to the patient’s.

In a collaborative therapeutic alliance, the patient is not a passive recipient but an active collaborator in therapy. He or she contributes to decisions—such as the length of therapy and topics to be discussed—and gives feedback on interventions and therapist style.

Focusing on life goals makes therapy meaningful to the patient.

Set priorities. Because only one or two therapeutic interventions can be tried during a medication-monitoring visit, problems need to be prioritized. As with Ms. W, the first visit’s goal was crisis intervention: to reduce suicidal thoughts and prevent hospitalization. Table 1 offers a framework for effective therapeutic interventions.

Save time by giving patients out-of-session assignments, which:

  • collect important information to review with patients during the next monitoring session
  • help empower patients to manage their symptoms.

Adaptive strategies—such as drill and practice 17 —can help improve learning in patients with cognitive impairment, which is common in psychotic disorders. 16 Give the patient a pocket notebook to write down what he learns in sessions, and encourage him to review the material at home. Call this a book of coping skills.

IMPROVING ADHERENCE

Medication nonadherence and partial adherence can result from:

  • illness-related factors such as lack of insight
  • patient-related factors such as attitudes and beliefs about medication
  • treatment factors such as side effects
  • physician-related factors such as showing an authoritarian attitude toward patients
  • system-related factors such as treatment access problems.

Interventions that respect individual autonomy and responsibility enhance long-term adherence ( Table 2 ), whereas those that invoke fear—such as threats of hospitalization—are ineffective and demoralizing. Improved medication adherence can reduce hospitalization and health care costs. 18

Table 2

Interventions to improve patient medication adherence

Issue

Intervention

Assessing medication adherence and beliefs

  • Specific questions (“Did you miss any doses since we last met?”) give most-accurate information
  • Questions such as “What does taking medication mean to you?” help clarify patients’ beliefs

Dysfunctional beliefs about medication (“Taking it means I am weak.” “It can turn me into a zombie.” “I will be dependent on medication.”)

  • With the patient, examine evidence for dysfunctional beliefs about medication
  • Acknowledge possible adverse effects; encourage patient to persist through mild side effects
  • Provide objective information about the medication, including views of patients who did well on it

Lack of insight (“I do not need medication”)

  • Help patient identify early subjective psychotic symptoms (insomnia, restlessness, racing thoughts)
  • Encourage patient to examine what life is like when on versus off medication
  • Have patient ask a trusted family member or friend how he or she is different on and off medication

Forgetting to take medication

  • Help patient set up medication routine and stick with it
  • Advise patient to buy an alarm clock and set it to sound when medication is to be taken
  • Encourage patient to keep medication in a prominent place, such as at bedside
  • Encourage him/her to use a medication organizer

Lack of a shared understanding of the illness between patient and physician

  • Encourage patient to state why he/she takes medication
  • Explore patient’s understanding of the diagnosis
  • Develop an explanation that makes sense to the patient and provides a reason to take the medication (such as, “Medication can help me achieve my goals”)

CASE: NOT REALLY HER FATHER

By the second session 1 week later, Ms. W’s suicidal thoughts had become infrequent and mild, and she was using the coping card as needed. This visit focused on visual hallucinations associated with anxiety about facing her father. We encouraged her to describe the hallucinations in great detail, and she realized that she visualized her father as he had looked 20 years ago, not as he looks today. Her anxiety decreased as she considered that she might be seeing not him but an image. Her homework assignment was to closely observe the hallucinations. Because she was more stable, the next visit was scheduled in 2 weeks.

By the third session, she reported that the visual hallucinations had disappeared, and the focusing technique had helped her. She continued to hear voices, however, particularly in the evening when she was alone and anxious or depressed. With prompting, she identified activities she could engage in at night, such as calling her mother and praying with her mother on the phone. This reduced her loneliness and helped her relax.

Table 3

Interventions to manage auditory and visual hallucinations

Problem

Intervention

Acting on hallucinations

Ask questions such as:

  • “What do you say to yourself when the voices command you and you ignore them?”
  • “What do you say to yourself when the voices command you and you follow the command?”

Tell patient, “It is not the voices themselves but the thoughts in your mind in response to the voices that determine whether or not you follow them”

List thoughts patient generates when choosing not to follow voice commands and encourage patient to read the list when hearing voices

Triggers of negative emotions that cause voices

Ask questions such as:

  • “What kind of moods bring on the voices?”
  • “Are the voices more likely to be triggered by anxiety, anger, frustration, or boredom?”
  • “Can you keep track of what triggers the voices from now to the next visit?”

Identify techniques to deal with triggers and rate their effectiveness

Dysfunctional beliefs that voices cannot be controlled or are prophetic

When voices are strong, coach patient to rate them on a scale of 0 to 10, try different distraction techniques, and rate them again

Encourage patient to write down what the voices say and whether their prophecies come true; reviewing the record in subsequent session shows voices are not prophetic

Voices during the session

Hum a familiar tune with patient

Ask patient to read out loud

Visual hallucinations

Encourage patient to examine details of what they see; this alone can make hallucinations disappear

Encourage patient to try to make hallucinations funny, such as making the image’s nose long (personal communication: e-mail Morton Sosland MD)

One month later, the voices had diminished greatly, and Ms. W returned to her regular medication monitoring appointments of every 6 to 8 weeks.

MANAGING POSITIVE SYMPTOMS

In serious mental illnesses such as schizophrenia, the most common hallucinations are auditory ( Table 3 ), 19 followed by visual and other types. 20 Sometimes patients view hallucinations as helpful, providing reassurance, advice, or companionship. The content may be an expression of the patient’s own beliefs.

Table 4

Interventions to help patients examine common delusions

Symptom

Questions to ask the patient

Behaviors of acting on delusions

  • “Let’s examine how your belief and behavior in response to it affect your life, both positive and negative”
  • “Is this belief helping you advance in life or hindering you?”
  • “Is this belief helping you reach your goals?”

Delusion with changing conviction

  • “When does this belief bother you the most?”
  • “When does this belief bother you the least?”
  • “How are you feeling right this minute? Is it bothering you at all?”
  • “What is it about some situations that make you less bothered by this belief?”

Delusion with complete conviction

  • “When did you first have these thoughts?”
  • “Did you believe in them right away, or did you have doubts?”
  • “What were some of the doubts you had?”
  • “Do you still have those doubts?”

Addressing underlying beliefs

  • “What does it mean to you to believe in this?”
  • “How would life be different if you did not have this belief?”

Delusion associated with lack of real world knowledge

Provide real-world knowledge. For example, for delusion that people can read a patient’s mind, inform patient that scientific experiments have shown that no one can read complex thoughts of others

Delusion involving physician

For example, say, “It is normal for you to sometimes question my intentions and believe that I am part of the conspiracy. I can assure you that is not the case. Anytime you have those doubts I would like the opportunity to clarify those for you. Can I rely on you to bring those doubts to my attention?”

When patient’s body language or behavior changes, ask if patient is suspicious and paranoid about you

Behavioral experiment for delusions

For example, a patient believed people parking cars on his street would break into his apartment. Homework was designed with two columns on a paper, one for him to check when someone parked and the other if they broke in. Next visit, patient returned with no checks in the break-ins column

When a patient such as Ms. W has hallucinations, consider four questions:

Continued...
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