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.
Why drug therapy alone is not enough
Table 1Pharmacologic 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 all5
- functional improvement does not always follow symptomatic improvement6
- 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
5 steps in effective cognitive-behavioral interventions
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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