Psychotherapy in Psychosis: Experiences of Fully Recovered Service Users, 2018

Link: https://www.frontiersin.org/journals/psychology/articles/10.3389/fpsyg.2018.01675/full

Authors: Bjornestad, J., Veseth, M., Davidson, L., Joa1, I., Johannessen, J.O., Larsen, T.K., Melle, I., & Velden Hegelstad, W.t.V.

Quotes:

“Therapeutic approaches sensitive to stage specific functional challenges seemed crucial for counteracting social isolation and achieving full recovery. Findings indicate that psychotherapy focusing on early readjustment to everyday activities, to what are perceived as meaningful and recovery-oriented, seems to be what is preferred and called for by service users.” 

“In psychosis, standardized treatment guidelines recommend psychotherapy (National Institute for Clinical Excellence [NICE], 2014). Meta-analyses show positive effects both on symptoms and recovery (Lysaker et al., 2010; Jones et al., 2012; Okuzawa et al., 2014), especially for therapies >20sessions (Sarin et al., 2011). “

Help with the Basics category:

‘These first treatment steps often gave rise to a feeling of safety and hope.”

“Early reduction of frightening positive symptoms, such as negative voices, was seen as crucial to alleviate pain, and obtain a feeling of mastery. “

“Being reassured that they already had been handling their positive symptoms gave patients a boost in self-confidence, reduced anxiety and helped them (in their experience) prevent new episodes.”

Having a Companion When Moving Through Chaotic Turf category:

 “All participants emphasized that liking their therapist, on a personal level, was crucial for a positive treatment outcome.”

“It may be this, being allowed to be exactly who you are and that there is somebody who understands you and knows your story and has backed you....”

Creating a Common Language category:

“Participants described therapy as a language- creating process.”

“Some participants also explained how delusions became less engrossing and became more manageable through repeated, targeted and corrective conversations about delusional content.” 

Putting Psychosis in Brackets and Cultivate All That Is Healthy category:

“The approach of distinct and explicit pressure– i.e., pressured the participants to participate in a social setting when they wished to be socially withdrawn– was perceived as highly effective and concurrently anxiety provoking.” 

Building a Bridge From the Psychotic State to the Outside World category:

“In order to recover, participants saw it as crucial to break the pattern of passivity and what they perceived as being excluded from the community. Recovery, to them, related to creating a meaningful place in society.” 

“I think really what it is about is finding something meaningful to get out of bed for.”

“Everything should be focused on functioning in society, not on functioning well in the psychiatric ward.” 

“Echoing previous studies, findings indicate an early solid psychotherapeutic alliance to be pivotal for a positive course of treatment (Safran and Muran, 2006; Horvath et al., 2011; Priebe et al., 2011). Early therapy was focused on safety and establishing basic structures, while the achievement of full functional recovery and regaining the role of an ordinary citizen was prominent in the later course.”

“Helping Service-Users Recover Using Sensitive Pressure  Participants expressed an explicit desire for a targeted therapy shortly after the acute phase abated. Here, touching the field of self-agency research (Frith, 2014; Bjornestad et al., 2016a), alliance research (Safran and Muran, 2006; Farrelly and Lester, 2014), and consistent with Vygotskys concept of “scaffolding” (Vygotsky, 1980; Davidson et al., 2011) therapists responded by conveying the message that participants had to take the role of active agents in their own change toward recovering.”

“Thus, a vigilant and sensitive therapist, constantly adjusting to the increased tolerance of the participant seemed crucial for psychotherapy to be assessed as meaningful and effective.” 

“The approach of early sensitive pressure seemed particularly effective in fighting social withdrawal. However, and in line with systematic reviews and meta-analyses (Farrelly and Lester, 2014; Wampold and Imel, 2015), findings indicate that mutual respect, personal closeness, and perceived therapeutic support were a precondition for the therapist to get into a position of exercising such pressure. This approach thus contrasts with a traditional treatment approach primarily focused on risk, ill health, and disease. Instead, findings indicate that therapy focusing on early readjustment to everyday activities, to what is perceived as meaningful and recovery-oriented, especially increased functioning, seems to be what is preferred and called for by service users.”

“The main limitation concerns representativeness of the sample. Only two participants fulfilled criteria of core schizophrenia spectrum disorder at the time of the interview. All participants came from an area practicing early detection and intervention, which in itself has been shown to improve course and outcome.”

“This study does not offer the opportunity to single out the perceived helpfulness of therapy versus that of medication.”

Thoughts:

I found this intriguing. “Twenty-seven eligible candidates were contacted; of these, four people refused study participation and three were classified as non-recovered (subsequently after the interview), due to having only 50% part-timework-a criterion being full time employment. “ The fact that the 3 were termed non-recovered but were actually working part-time makes me have so many questions. I know many individuals who feel that working part-time is a wonderful part of their life and might not necessarily say they aren’t “recovered.”

“At inclusion participants agreed to baseline assessment, and follow-up after 3 months, and 1, 2, 5, and 10 years. “ So great that they followed up in both short and long intervals to get a more full picture. So many only follow up for less than 2 years and long-term studies show a lot of progress of psychotherapy treatments after the 2 year mark. 

“The study sample comprised 10 females and 10 males, all ethnic Norwegians. At the interview time-point, they were all living independently and were in full-time employment or education and average years of education after mandatory school (equals high school level) was 1.15 years (range 1 4years).” All living independently and in full-time employment or education. That is so great. It not only points out that people deserve to get through the experience so they can find what interest they want to pursue but also so great to just see that it's there. That it can occur. That it is occurring in some places already. We need to catch up. 

“The average age at inclusion was 25.8 years (range 17–58 years) and median duration of untreated psychosis was 12 weeks (average 26.5 weeks; range 0–156 weeks).“  12 weeks is so great! US DUP is 74 weeks, Finland is 3 weeks. 12 weeks is just over the length of a summer break from school. What a wonderful difference to have a shorter time period. “The duration of untreated psychosis was significantly shorter among participants compared to non eligible and non-included subjects of the larger TIPS study.” I’m super curious about this. I wonder what the DUP would have been if they had included individuals who had part-time work or other factors. 

Discussion topics:

Is this something that you would want to share with treatment team members?

Do you feel that any of these already relate to connections you have made in treatment?

Look ups:

Lehman’s Quality of Life Interview (Lehman, 1996)