Psychosocial+and+Psychotherapy+Interventions

=**__Early Psychosis Intervention Programs__**=

Over the years studies have indicated that youth are less likely to engage in traditional medical model approaches to care, which ultimately results in lowered levels of medication compliance and longer durations of untreated psychosis (DUP) (Larsen et al., 2001). With the increasing recognition of the association between longer DUP and poorer long term outcomes, regions across the world have now started to implement psychosocial interventions that target First Episode Psychosis (FEP) clients during the early prodromal stage of their illness (MOHLTC, 2004). Commonly referred to as Early Psychosis Intervention (EPI), these programs seek to improve both the short- and long- term outcomes of both the positive and negative symptoms of psychosis (MOHLTC, 2004). Using the same framework as Assertive Community Treatment Teams (ACTT), EPI programs are community based services that offer in vivo treatment by a multidisciplinary team 24 hours a day (Regehr & Glancy, 2010). EPI teams are typically comprised of a psychiatrist or psychologist, social workers, youth workers, registered nurses, an occupational therapist and an addiction counsellor (Archie et al., 2005). While working in collaboration with the other professionals and the client, the EPI team is responsible for developing flexible, individually tailored treatment plans that focus on the client's unique needs and promotes recovery (MOHLTC, 2004). Although the range of programs may vary between EPI programs, key service components that can be found in most early intervention programs include: (MOHLTC, 2004)
 * //Facilitating Access and Early Identification:// public education, awareness raising, assertive outreach, initial screening
 * //First Response:// crisis intervention, psychiatric assessment, in-patient stabilization
 * //Treatment Services:// psychiatric consultation and follow-up, medication monitoring, case management, psychoeducation provided to consumers and the family, individual supportive counselling, treatment of comorbid conditions, addictions intervention
 * //Psychosocial Support:// supportive housing, educational/academic assistance, vocational/employment assistance, recreational, social (e.g. activities focused on spirituality or those centered around developing the skills necessary to build social/intimate relationships), support groups[[image:bmws-admh-2011/modelofintervetnion.gif align="right"]]

(CMHA, 2000)
 * Consequences of delayed treatment can include:**
 * Disruption of life course
 * Problems in relationships
 * Increased likelihood of substance abuse
 * Increased risk of depression and suicide
 * Loss of self-esteem and self-identity
 * Increased likelihood of hospitalization
 * Slower and less complete recovery
 * Poorer prognosis

(CMHA, 2000)
 * Reasons for treatment delays include:**
 * Inability of the individual, family or professional to recognize the signs and symptoms of psychosis, especially if symptoms emerge gradually
 * Inability of persons experiencing psychosis to perceive themselves as ill
 * Fear and stigma associated with mental illness
 * Limited access to appropriate services

Compared to FEP client's who receive treatment as usual, outcome studies have suggested that individuals who remain engaged in EPI programs for a period of 3 years, have increased speeds of recovery, reduced hospitalization, decreased socio-economic burden, reduced secondary psychiatric function (e.g. depression, substance abuse), less family disruption and greater vocational and educational achievements (MOHS, 2010). Additionally, research indicates that EPI programs greatly increase a client's overall development of psychosocial, life skills and role functioning (MOHS, 2010).

Due to the fact that Tom is currently admitted to an inpatient psychiatric facility it would be a critical time for him to be referred to an EPI program in order to reduce his overall DUP. While still receiving inpatient care Tom's EPI team may begin to link him to various recreational, social and support groups in an effort to reduce his isolation and increase his level of interaction with more positive peers. Once discharged from the hospital it would be important for the member's of Tom's EPI team to monitor his medication to ensure medication compliance. Depending on Tom's goals it may be important for his case manager to offer educational or vocational assistance so Tom can either complete his schooling and/or obtain employment. Since this is Tom's first experience with psychosis it would be important to incorporate psychoeducational elements along with supportive counseling to normalize his experience, into his treatment plan. Finally, it may be necessary for the addictions counsellor to work with Tom surrounding his use of marijuana as a possible coping mechanism.
 * //Case Example//**


 * __Note:__ To locate an EPI program in your area please visit @http://www.earlypsychosis.com/directory/

=**__Cognitive-Behavioural Interventions__**=

Despite the numerous advances in psychopharmacological and psychosocial interventions, approximately 20 to 45 percent of individuals will experience persistent symptoms, namely delusions and hallucinations, that will continue long after they enter into the recovery stage of their illness (Rathod et al., 2010). In an effort to relieve individuals of these chronic symptoms, clinicians have begun to employ interventions that focus on the thought processes that maintain the distorted thinking and subsequent behaviour (Regehr & Glancy, 2010). Originally developed in the mid 1950’s by Albert Ellis, Cognitive-Behavioural Therapy (CBT) has emerged as a highly effective intervention strategy for helping individuals experiencing an FEP to manage their symptoms (Chadwick & Trower, 1996). CBT works on the premise that an individuals thoughts and beliefs regarding a specific, or 'activating' event, ultimately cause their feelings and behaviours (Chadwick & Trower, 1996). Expanding on Ellis' ABC model, Chadwick and Trower (1996) developed one of the first and arguably most influential cognitive-behavioural frameworks for working with individuals experiencing active delusions and hallucinations.

When developing their model Chadwick and Trower (1996) proposed three primary stages of intervention. During the first stage, the clinician, while building rapport with the client, should begin to identify the delusional beliefs and/or hallucinations that the client holds (Chadwick & Trower, 1996). In the second stage the clinician continues to gather further information regarding the client’s thought processes in an effort to draw out evidence that supports or negates the client’s belief (Chadwick & Trower, 1996). The focus of the clinician in this stage is to determine the underlying factor that is is driving and reinforcing the client's dysfunctional thought and/or behaviour as well as the client's feelings and/or reactions to it (eg. angry, scared) (Smith et al., 2003). The third, and perhaps most important stage of the model is where the clinician actively begins to challenge the client’s thoughts. During this stage Chadwick and Trower (1996) propose four alternative steps for the clinician to follow when challenging the client’s belief. In the first step, the clinician should draw on the distorted belief and present it to the client (Chadwick & Trower, 1996). Second, the clinician highlights all of the irrational or inconsistent features of the client’s belief system (Chadwick & Trower, 1996). Using the information gathered in the second stage of the model, the clinician then works in collaboration with the client to develop alternative explanations or helpful alternative beliefs (Chadwick & Trower, 1996). The goal of this third step is to get the client to ask him or herself, “How can I think differently?” (Smith et al., 2003). After exploring alternatives, the clinician should help the client develop more rational explanations for his or her distorted thought(s) (Chadwick & Trower, 1996).

When explaining CBT for a FEP client it may be helpful to consider the case example of Tom. __//Stage 1://__ In this stage the clinician at the hospital will be actively listening for Tom to present his delusions and/or hallucinations. The information the clinician would want to draw on would include such things as: aliens are after him, aliens are taking thoughts out of his head and finally, that aliens are whispering to him. //__Stage 2:__// In this stage the clinician would be looking at both the beliefs Tom holds regarding the aliens and the consequences of these beliefs. For example, if Tom believes the aliens are trying to take thoughts from his head, is that making him feel anxious, threatened etc. The clinician may ask Tom, "When this was happening, what are you thinking?", "How did you feel?" Additionally, the clinician will want to link Tom's emotions to his current actions (burning paper in his room), to determine how his feelings and beliefs have contributed to this behaviour. //__Stage 3:__// In this third step the clinician would present Toms irrational belief that aliens are trying to steal his thoughts to him. Depending on the information elicited from Tom in the previous stages the clinician may say things such as, "If you have never seen the aliens, what makes you so sure they are there?". The clinician would then work with Tom to develop other possible explanations for the noises or "voices" he was hearing. In this step the clinician may ask Tom, "What else could it be other than voices you are hearing?"
 * //Case Example//**

Research has shown that when applied correctly, CBT interventions produce not only a reduction in positive symptoms, but also the negative symptoms an individual may be displaying (e.g. increased levels of self-esteem) (Tarrier et al., 2001). Similarly, because CBT has been proven as an effective treatment for other mental illness such as depression and anxiety, with minimal amendments to the above treatment framework, clinicians can successfully treat many comorbid mental health issues as well (Regehr & Glancy, 2010). Finally, it is important to note that due to the complex thought processes that are involved in CBT, client's participating in this form of treatment must be considered relatively high functioning. As a result, CBT is often used after the client has began pharmacotherapy treatments in the acute phase or during the recovery phase when individuals have begun to regain normal levels of functioning (Regehr & Glancy, 2010).

=__**Family Intervention Strategies**__= Over the years, research has indicated that 60 to 77 percent of mental health consumers either live with their families or have some ongoing contact with them (Regehr & Glancy, 2010). Since an overwhelming majority of individuals with FEP are young, it is believed that these percentages are even higher. As a result, recent efforts have been to develop interventions that target the individuals within the FEP client’s social support system (Regehr & Glancy, 2010). The theoretical basis behind this model of intervention is that families can provide a good buffer for the negative impact associated with FEP and consequently, those individuals with a strong support system tend to see more positive results (Regehr & Glancy, 2010). Typically, the focus of family interventions will be on psychoeducation, which includes, identification of warning signs, the importance of attributing maladaptive behaviours to the illness rather than the FEP client’s personality, communication and methods of decreasing familial criticism, hostility and over involvement (Penn et al., 2005). Additionally, due to the high levels of distress found among relatives caring for a person experiencing a FEP, family interventions may also focus on loss and grieving, expressed emotions (EE) and emotional support (Gleeson et al., 2003). Although family interventions may be seen as a less direct approach to working with an FEP client, outcome studies have continuously shown that individuals who received family treatment spent significantly less time in hospitals and/or shelters (Penn et al., 2005). Similarly, other research has indicated that family interventions are effective in reducing positive symptoms, increasing social functioning and delaying the rate of relapse for periods of up to 2 years (Spencer, Birchwod & McGovern, 2001).

Since Tom still resides with his family, it may be highly important to incorporate family interventions into his treatment plan. Due to the fact that this is the family's first incident with psychosis it would be important for a clinician to educate both Tom's parents and siblings about the symptoms, characteristics and long term outcomes of FEP. Additionally, it would be critical for the clinician to work with Tom and his family members to develop a supportive environment for when Tom returns home from the hospital. The family intervention may also incorporate emotional support for the family members and act as a safe place where each of the members can explore their feelings and thoughts regarding Tom's FEP diagnosis.
 * //Case Example//**