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Psychological Interventions in Early: A Treatment Handbook Paperback – 13 Apr 2004

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"...provides an extremely informative guide...clearly written...an invaluable guide..." (Psychological Medicine, August 2005; Issue 35)

From the Back Cover

Psychological Interventions in Early Psychosis provides a comprehensive overview of the emerging research and clinical evidence base for psychological treatments across the phases of early psychosis. Beginning with identified at–risk young people, the text continues through to those in acute and recovery phases, to the needs of patients with persistent symptoms. 

This practical treatment handbook:

  • draws upon the expertise of several internationally recognised clinical and research programs
  • ntegrates reviews of the relevant research literature with illustrative case examples
  • covers critical issues for the clinician in focal chapters on suicide prevention, comorbid cannabis abuse, and family work
  • describes several modalities of treatment, such as multi–family psychoeducation, group work, psychodynamic and cognitive behavioural approaches.

Specialist early psychosis services are developing rapidly worldwide. Psychological Interventions in Early Psychosis will be an essential resource for clinicians and service leaders alike.

Contributors:
Jean Addington, Canada
Karen Barton, UK
Max Birchwood, UK
Peter Burnett, Australia
Johan Cullberg, Sweden
Larry Davidson, USA
Jane E. Edwards, Australia
Kathryn Elkins, Australia
Gráinne Fadden, UK
Paul R. Falzer, USA
Shona M. Francey, Australia
Donna Gee, Australia
John F.M. Gleeson, Australia
Gillian Haddock, UK
Kate Hardy, UK
Lisa Henry, Australia
Tanya Herrmann–Doig, Australia
Mark Hinton, UK
Zaffer Iqbal, UK
Chris Jackson, UK
Jan–Olav Johannessen, Norway
Ashok K. Malla, Canada
Rufus May, UK
Terry S. McLean, Canada
Patrick D. McGorry, Australia
Ross M.G. Norman, Canada
Lisa J. Phillips, Australia
Paddy Power, UK
Ron Siddle, UK
David A. Stayner, USA
Darryl L. Wade, Australia

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Amazon.com: 2.0 out of 5 stars 1 review
4 of 8 people found the following review helpful
2.0 out of 5 stars Not a Treatment Handbook but Not All Bad 12 Sept. 2006
By Pen Name and That A - Published on Amazon.com
Format: Paperback Verified Purchase
This book has multiple authors, so I will review each chapter individually.

Chapter 1: Background and overview.
------------------------------------------------
As with most multi-author books, the first chapters are the best ones. A psychotic prodrome is defined as a period of symptoms and increasing disability that occur before the onset of sufficient positive symptoms to allow the diagnosis of schizophrenia. The possibility of a psychotic disorder should be considered, the book says, in any young person who is becoming more socially withdrawn, performing more poorly for a sustained period, behaving in an unusual manner, or becoming more distressed or agitated and unable to explain why. Unfortunately the book does not detail the mental state findings than can be predicative of a psychotic disorder. Some practitioners experienced in early psychosis can recognise the risk of a psychotic disorder on video that is not apparent to general psychiatrists (I saw from personal experience at an APA course).

Throughout the book are references to maintaining morale and general psychological help, but this is not systematically gathered together, obliging the reader to cobble together their own list as they read: sense of self, self esteem, continuity of care, coping strategies, accurate empathy, education about psychosis and medication, CBT for symptoms and underlying schemas, improve adaptation, improve interpersonal relationships, assist the family, vocational recovery, reduce the risk of suicide and agression, prevent relapse, substance abuse, advocacy, hope.

The book points out that case management should follow the assertive model and that primary care and shared care should not be undertaken. They give the usual recommendations that in fully remitted patients antipsychotics should be continued for at least 12 months and then withdrawn over at least several weeks. My view is that surely that withdrawal period is too short, although is practice the withdrawal period is all ways determined by the patient. At least 20% of patients fail to fully remit after two medication trials. Cognitive remediation is not presented as having sufficient data and I think that is still true.

McGorry states "elsewhere I have outlined a simple three-level model to grade the complexity of interventions in early psychosis." Levels 1 and 2 include psychoeducation, crisis support, supportive psychotherapy and relapse prevention strategies and should be available to all patients. Level 3 includes CBT for early treatment resistance, suicide risk reduction and substance abuse and should be offered on an as-needed basis. True and followable, but the theme of referring the reader elsewhere for the contents of a "handbook" recurs throughout this book. Another aspect of this chapter carried through the book is that the authors state how critically important and good their treatment is but do not have much data to support their assertions!!!

Chapter 2. PACE.
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Psychological interventions in the prepsychotic phase. This chapter outlines the approach to people at ultra high risk (UHR) further subdivided to: attenuated psychotic symptoms group (with subthreshold psychotic symptoms), limited intermittent psychotic symptoms (frank psychosis less than a week), trait and state risk group with relatives with schizophrenia. The members of the above groups had a 40% chance of developing a psychosis in the next 12 months, which seems a pretty good outcome.

A study was done on the above groups. CBT and low risperidone did better than supportive therapy alone. That is not surprising and what surprises me is that the EPIC seems to have a pretty high threshold for starting antipsychotics. The two groups were the same at 6 months, however. This is another theme of the book: the authors talk on and on about how important the first few months of the psychosis are and how well CBT works but their own data do not support such assertions! The effect washed out after six months! The other problem (recurring) is that details of the study were not given.

The PACE Model: 15 x 45 min sessions starting weekly and becoming less often. The stress vulnerability model of psychosis is taught so the patient will be more empowered and adherent with their treatment. Other modules: stress management, positive symptoms negative symptoms/depression, other Comorbidity.

The first phase of the PACE model is: Assessment/Engagement: ground rules, collaborative, practicable help, education about symptoms, goal setting. And case management is provided.

Stress management module: relaxation training, education, stress monitoring, stopping maladaptive coping mechanisms, basic RET with monitoring of thoughts, goal setting, assertiveness, problem solving strategies.

Positive symptom module: Normalise symptoms (but they don't say how, and this is an area of CBT that is specific to psychosis! For example Kingdon and Turkington mention likening hallucinations to dreaming while you are awake.) Coping strategies, reality testing with behavioural experiments, use of socratic questioning.

Negative symptoms module: (Note for later: this chapter has the good sense to point out that negative symptoms develop during the prodrome.) The treatment is as for depression and includes goal-setting, scheduling and mastery, problem solving, social skills training, and RETs (again).

Other co-morbidity module: Basically basic CBT for anxiety and substance abuse.

In other words, PACE consists of all the standard CBT stuff that you do for anyone else plus some specific stuff that they do not tell you how to do. They also do not mention, anywhere in the book, that over forceful rehabilitation can make people relapse (ref: Hogarty for example).

Chapter 3: CBT for Acute and Recent Onset Psychosis.
-------------------------------------------------------------------
Generally time-limited, collaborative, and emphasizing improvement in functioning and reducing distress rather than symptom removal or cure. Quotes Haddock et al with non-specific benefits of CBT for psychosis that were not statistically significant.

The SoCRATES study: Showed no over all improvement for CBT versus supportive counselling, but when individual symptoms were examined, those with hallucinations did better with CBT. Involved, in practice, on average 8.6 hours of therapy per person. Involved drug and alcohol motivational interviewing.

Specific elements of the intervention: warm manner, personal disclosure by therapist, clarify symptoms rather than question them, develop a patient-driven problem list. Normalizing symptoms: they quote Kingdon and Turkington but do not mention the method above but mention stating that symptoms are on a continuum: i.e. the "handbook" mentions it again but does not say what to do.

Working with delusions and hallucinations. This is by far the best bit of the book and is actually hand-book like.

1. Peripheral questioning: ask peripheral questions about delusions. For example, how big an implanted device might be and if it would need batteries and if it would show up on xrays. Tread narrow line between reinforcing and challenging the delusion. Mild paranoia and conspiracy beliefs can be normalized. Deficits in basic general knowledge can be addressed. Written list of evidence, perhaps.

2. Consideration of the evidence. Would the evidence convince a jury? Does everybody think this way?

3. Helping the patient consider alternative explanations. Can provocatively suggest silly causes of voices such as aliens, when the delusion is about the devil, for example. This gets the patient used to dismissing suggestions. Does the voice only say things that you all ready know? This can be tested with behavioural experiments, like checking if the patient really is telepathic.

4. Coping strategies. Recorded coping messages and coping cards. Distraction like counting backwards from 1000 by sevens, counting other objects, focusing on input from specific sensory modalities. This bit of the book gets a little close to mindfulness but, of course, never gets close enough to tell you about it.

5. Negative symptoms. As above for depression but note disability secondary to boredom or drowsiness.

6. Working with core beliefs. Here the book states, and I quote, page 56 "Core beliefs or schema are often considered to be at the heart of a person's vulnerability to psychosis." The reference for this is Perris and Skagerlind, 1994, Acta Psychiatrica). This is a BIG CALL and would make a decent focus for the book. Considering that the Nordic Investigation of Psychotherapeutically-orientated treatment for new Schizophrenia (Alanen 1994) was inconclusive! The statement implies that psychotic symptoms are psychologically meaningful and I do not think that there is any good evidence for that; more about that later.

7. Staying well. Standart relapse prevention stuff, but light on for specifics; more about that later too.

4. Psychological Intervention in Recovery form Early Psychosis.
--------------------------------------------------------------------------------
More stuff about morale: human experience, impact, how does one cope, what is one's understanding of what happened, self stigma (I can imagine what self stigma is but it is never explained at all or what to do about it!).

The intervention is based on two premices: one of which is the critical period of 2to5 years. You guessed it, no data that the critical period is critical in that intervening her helps. Remember the washout above.

Therapy overview: repetition of other stuff and motherhood statements.

Assessment therapy phase: standard but with more morale stuff like: aspirations, hopes, goals. They also said to write paragraphs about experience of hospital, experience of being unwell, why do you think that this happened to you at this point in your life (the correct answer to this is "age-related brain development with earlier abnormal development because of bad luck but no one knows the details," but I do not think this is the expected answer for the patient who probably has been taught that the psychosis is psychologically meaningful!).

Adaptation therapy phase: more morale stuff, this time including the search for meaning from the experience (no doubt an allusion to Man's Search for Meaning which is more applicable to an older age group, I think, even though it was written by a young man), mastery and enhancing self esteem. Hope is again instilled with the stress vulnerability model (see above). The concept of possible selves (Markus and Nurius 1986) is introduced and briefly explained (!). A time line can be used to summarise a person's life and help them differentiate between what about them is related to their illness and what is related to the rest of them. (Freud came up with the idea of neither over identifying nor rejecting an illness, so this is a sort of original idea). More morale stuff now: using the person's strengths, supports, interpersonal and communication skills, personality style and insight. And using the patient's own explanatory model.

5. The dynamics of Acute Psychosis and the role of dynamic therapy
------------------------------------------------------------------------------------
Quote from page 86 "Hogarty has developed a model called `personal therapy.' It is not clear whether he included his model among the dyanamic therapies." I did not understand Hogarty's book either. Guilford Press, the publisher of Hogarty's 2002 book declined to publish another book he later offered them.

The case example from this chapter is of a 30 year old woman who was successfully treated psychodynamicly after medication and ECT had failed and been stopped. This the best recommendation you can give a treatment when the trials have all failed. To be fair, it is a stunning result. I think the case would be better pictured with Colin Ross's trauma model. (Great model, look him up on Amazon and buy the book). The case history hints that the patient's child hood home was abusive but does not explicitly state if this was so or even if trauma had been enquired about!!! Instead of hypothesizing that trauma could have been central, the case gives a laundry list of problems and neuroses as an explanation for the psychosis. If you or I saw the patient, we might have diagnosed her with a personality disorder from the outset but the issue of a basically wrong diagnosis was not given. I do not think that it is a coincidence that the case of successfully psychotherapeutically treated "schizophrenia" was in a case with a person who probably had a history of severe trauma.

6. Working with Families in the Early Stages of Psychosis
-----------------------------------------------------------------------
Ideas: fear, guilt, anger, objective burden, subjective burden, (expressed emotion) EE. I did not know that EE was an empirical construct derived from the Camberwell Family Interview. The chapter goes on to say that "the present measures of EE are too long" to use and that "the validity of the shorter measures remains equivocal." Think about what this chapter just said, people: EE is not a clinically useful concept!!! Needless to say, they do not tell you how to determine if it is present, beyond stating is concepts of over involvement and hostility!!! That's not much help, people!!!

The chapter states that the help of family programmes is unequivocal. That is helpful information. How you do it is: 6-8 sessions, with education about psychosis, support and coping strategies. EPPIC has families attend several groups with other families and no patients. Good idea and something I might not do enough of. The concepts for treatment of the family are much the same as for treating an individual, which is convenient: education, problem solving, communication, stress-vulnerability but includes setting limits. This not being an actual handbook does not tell you how to do any of the stuff, but. Oh, there's no outcome data.

7. A Group Psychotherapeutic Intervention during Recovery
-------------------------------------------------------------------------
"Attendance is encouraged by calling the patients the day before and the same morning, if necessary, to remind them of the session. Rewards such as a coffee pass after each session or a package of lottery tickets after four sessions can be used to increase attendance. Using these techniques in a randomised-controlled trial of a 12 week stress management program (Norman et al., 2002), we were able to contain the drop out rates to 6% and 8% for the experimental and control group therapy conditions, respectively."

This is another bit of the book that is actually a treatment handbook

Session 1: Members introduce one another, talk about feelings about jointing the group, write a letter to themselves with their goals for the course, ground rules, socialised to check in and check out questions.

Session 2: Identity and what is psychosis. Members reintroduced. Leader can add additional information. People say what has sustained them through the experience. Education about growing up versus acting out activities. Likened to diabetes. Remember what their identity was before they developed the illness. Educated about psychoses and stages and shown the film "Reaching Out: the importance of early treatment." by British Columbia Schizophrnia Society; not available at Amazon or the BCSS.

Session 3: Peer pressure and substance abuse. The authors note that the idea of self-medication has limited empirical support and that youths use drugs, particularly high amounts, for the same reasons that other people do: loneliness, boredom, social anxiety, insomnia and peer pressure.

Check in exercise: my friends pressure me about... Shown The Secret Life of the Brain, episode 3, the teenage brain. Then play Jeopardy about psychosis facts.

Session 4: Relationships and medication. Check in: positive or negative change in relationship with family/spouse since what happened.

Session 5: Self-stigmatization. Check in: most embarrassing experience. Definition of stigma, comparison to AIDS or epilepsy. Divided into small groups to discuss stigma of mental illness in the home. Check out: compliment the person beside them.

Session 6: Recovery and social skills. Role play scenarios. Check out question: what would you do to improve your communication skills.

Session 7: Early warning signs, early intervention. Session 8: Review/celebration. Review the letters to themselves. The group shares a meal (Which I think is changing the relationship to compensate for it ending and they would be better talking it our and not acting it out).

The authors give half a page to the positive outcome study... and mention that the treatment arms were not randomised...

Chapter 8: Cannabis and Psychosis
--------------------------------------------
Authors point out: conventional preventative strategies based on education have failed to curb cannabis use in school-age populations. Unanswered question: can we do anything to reduce cannabis compared to treatment as usual.

The authors have a four area grid with using and not using cannabis on one axis and good thins and bad things on the other axis. The authors recon a good and bad things about cannabis grid is too simple, but I disagree. Maybe I am just dumb but I find the four area grid confusing.

The program, which is outlined, does not really take a constructional and functional behavioural view and the relapse prevention area is devoid of any real information, such as the abstinence violation effect or behavioural analysis of relapses. The authors of this chapter did not seem to know enough to do more than gloss over the actual interventions.

Chaper 9: The first psychotic relapse
----------------------------------------------
The authors point out that at nine years the relapse rate in one study was only 85% which suggest a safe point might be reached. They make the very intersting point that in relapse studies, small significant clinical changes might not be picked up by rating scales. Also, the construct of relapse: deterioration after partial or seeming recovery. Taking a dimensionional (and not a categorical) approach to symptoms might lead to less defencsive sealing over of curiosity and concern for oneself and one's illness.

They also pointed out that people with schizophrenia had higher rates than the general population of child abuse and patients with abusive histories had more dissociative symptoms and longer admissions than others with schizophrenia. Too little information here to be sure what is going on her regarding Colin Ross et al, of course.

45% of the general Australian population has reports cannabis in the last 12 months.

The authors recon "The successful prevention of relapse is based on the assumptions that (a) it can be accurately predicted and..." Which is silly, of course.

Relapse prevention strategies: monitoring of symptoms, compliance therapy, family psychoeducation and communication training, patient coping, cognitive interventions.
Compliance interventions: destigmatising youth orientated services, simple med regeims, depots, motoviational interviewing etc. Authors state noncompliance 75% in first 1 to 2 years but do not say what they mean by noncompliance (sigh).

Cognitive interventions: "This paradigm may be particularly useful for understand ing the self-perpetuating problems in David's case, by linking his enduring self-schema, and interpersonal schema, regarding powerlessness to his tendency to jump to conclusions of a paranoid nature." This is the same BIG CALL when you don't have data and don't restrict yourself to patients with a history of trauma.

Rates of relapse are given to decatastrophise actual relapse and make the patient more likely to describe it.

10. Suicide prevention in early psychosis
--------------------------------------------------
Which perpetuates the silly idea that homicide (especially of one's children), or chronic damage to one's children are not the really big thing to make sure do not happen. The authors point out that 2% of first episode people commit suicide with in one year of contact with services. Only about 10% of suicide attempts with schizophrenia are associated with command hallucinations. Also, there was a poor correlation between the Suicide Ideation Questionnaire (SIQ) and attempted suicide.

Two points the authors make about the LifeSPAN therapy described in this chapter: (a) their own data says it does not work, and (b) you can buy the manual from EPPIC.

11. Psychological Treatment of Persistent Postive Symptoms
---------------------------------------------------------------------------
You get ANOTHER paragraph about what EPPIC is. More CBT stuff, this time including making gentle connections between the contents of voices and disowned thoughts about themselves and exploring the psychological meaning of the voices. I thought psychodynamic therapy of schizophrenia did not work and that psychologist thought how dumb psychiatrists were for trying it.

Distraction techniques I have not heard of before: reading aloud, singing, humming and psychoeducation.

12. Cognitive Therapy and Emotional Dysfunction in Early Psychosis
-------------------------------------------------------------------------------------
This is were the book starts to deteriorate. The authors state "CBT, in other words, is widely regarded and evaluated as a `quasi-narcoleptic'. This has not unexpectedly led to resistance and, at times, hostility, as professional territory is challenged (McKenna, 2003). This is a bit naughty. The Turkington is the first author of the article which is a "for and against" article about CBT for psychosis where Turkington takes the for and McKenna takes the against. To use that as data of hostility because of particular psychological process is naughty and so is attempting to dupe the reader by using a reference that does very little to back up the preceding point. McKenna stated, amongst other things like the Hawthorne effect, that that the pooled effect of CBT studies with good methodology cancelled out. I am not saying McKenna was right. If someone wants to reference this article, they would have been better off telling me why McKenna was wrong, because clearly, some people think he is wrong. And another thins, in 2006 the Cochrane review of CBT for schizophrenia is that it is "promising," so McKenna was not alone. Other psychologists have made the same accusation of psychiatrists, however. For example, Quinsey et al 1998 Violent Offenders Appraising and Managing Risk, American Psychological Association; I am not sure about the current edition of the book.

Common elements of cognitive therapy in psychosis: engagement, assessment, formulation, coping strategies, psychoeducation, normalising, finding inconsistencies in beliefs, challenging evidence for beliefs, challenging power/omnipotence of voices and persecutors, empirical testing of beliefs, viewing content of delusions or voices in life context (trauma, neglect), improving the concept of self worth.

The above are good points. Listing trauma AND neglect is good because it emphasises that one needs to think of chronic neglect and not just specific examples of bad things that happened. Still no Colin Ross amount of information here. Colin Ross rates psychosis as a spectrum between biologically produced and trauma produced. It would be consistent with his model not to worry about psychological meaning of psychosis for people with biologically based disease. This is a bit of a problem with CBT in general- there has been too much effort proving that CBT is a good treatment and not enough effort matching treatment to diagnosis.

Review of the literature was long and weak. Listing trials and if they had a control group is not sufficient, especially in the light of the things about this chapter described above.

The basic theme of the chapter is that CBT should concentrate on fixing the suffering more than the positive symptoms. Problem for CBT is that the data seems to be that CBT is even worse at fixing distress than positive symptoms (although this is a little unfair of me to quote the chapter like this.)

More naughtiness with references: "There is evidence of a high rate of traumatic histories in people with psychosis, including sexual abuse (Greenfield et al., 1994)." Well, Greenfield's study had a sample size of only 38! I am not saying that the idea above is wrong, but putting in a token reference to give the appearance that you are making assertion based on something solid is naughty. In other words, if you believe something controversial, reference it with the data that made you believe it in the first place.

"In view of the fact that the psychotic symptoms were not identified by Phil as being a primary source of distress." In actual fact, people are no better at guessing what is upsetting them than an observer would be. This is an extremely important point; approximate reference: Nesbitt and Wilson 1977 "Telling more than you can know" Psychological Review: my favorite 37 pages of journal article ever.

13. Developing Treatments
----------------------------------
The authors recon that the idea that prodrome and negative symptoms are much the same is a new idea. The recon the idea that episodes of positive symptoms are not followed by an exacerbation of negative symptoms is not valid.

They recon more aggressive rehab needs to be done early to prevent progression of negative symptoms but they acknowledge the benefits of withdrawal early in the illness. The authors need to work out something basic: are they in favor of woodshedding or against it? I am in favor of it.

They also say to not attempt to eliminate anxiety from daily living. This is a ridiculous assertion for them to make.

They conclude with this "clearly, awaiting a wait ant see approach only leads to persons falling behing their developmental trajectories and ensuring their ultimate disablity." Well, I say to those authors that others have all ready tried to aggressively rehabilitate people all ready got the data to say that they did harm and you should not be writing book chapters.

14. Making Sense of the psychotic experience
---------------------------------------------------------
Good chapter. Stunning actually. Important question: what is the possibility that you can come off your medications and stay well? Maybe it depends on the subtype of your schizophrenia. Bur May did seem to have a genetic loading. But he did not say if his childhood was traumatic. The other fact is that May still gets some psychotic symptoms. I wonder what they are and what his personal experience of challenging his own cognitions is. Does he woodshed?

15. Implementation in Early Intervention Services
-------------------------------------------------------------
Quote "Clinician's time will always be precious." If this was recognised, this book would not have been published. I suspect part of the problem was that the authors and editors were not paid for their work and a multi author book was put together where the publishers and others did not try to make it all that they could. Perhaps they needed authors who were heavier hitters and if the book were edited more aggressively it would have shrunk away to nothing.

You know how this review is disordganised and repetative? Well, I reviewed the book chapter by chapter...
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