Psychosocial Interventions for Psychosis

1. Psychosocial Interventions for Psychosis Gemma Stacey

2. Aims • To gain an overview of the stress vulnerability model • To identify interventions adopted within this model: • Coping skills enhancement • Relapse prevention • Apply the model to practice based scenarios. • Consider how the model may inform your approach to working with people with psychosis

3. What do you believe causes psychosis?

4. Stress • It may be said that all life events cause some degree of stress due to the adaptation involved. • The Stress Vulnerability Model maintains people who eventually suffer psychosis already had a pre-disposition to the effects of stress.

5. What do we mean by stress? • Is it a physiological or psychological reaction? • Are there different types of stress? • Does it effect every person in the same way? • What happens with short term stress? • What happens with long term stress?

6. Actual Demand eg work, child care, life events Actual Capability eg health, resources, coping strategies Perceived Capability Perceived Demand Appraisal (How well we think we are doing) Imbalance = Stress Physiological Response Psychological Response Behavioural Response Stress and Stress Response Lazarus & Folkman (1984)

7. What do we mean by vulnerability? • When you think about people you have worked with, what factors do you think make them vulnerable to stress?

8. Stress Vulnerability Model • Vulnerability Factors pre-disposeindividuals to develop problems e.g psychosis • Problems are triggered by stress • If vulnerability is high, low levels of environmental stress may trigger distress • Use and effectiveness of coping strategies goes some way to explain why some have problems and others don’t

9. A Stress &Vulnerability Perspective Assumes • The experience of psychosis is understandable. • Problems associated with the effects of stigma, social exclusion and poverty are of equal importance. • We take a collaborative approach to assessing, planning, formulating and delivering care.

10. A Stress &Vulnerability perspective assumes • Each person is an expert in their own care. • Psychosis is on a continuum with other human experiences. • Psychosis can be an enriching, as well as a frightening/confusing experience. • The person over time, can make a recovery, in terms of what that actually means to them

11. Stress Vulnerability Model Zubin, J. and Spring, B. (1977) Vulnerability. A New View on Schizophrenia. Journal of Abnormal Psychology 86, 103-126. APA. Reprinted with permission

12. The bucket

13. Formulation Personal vulnerabilities Personal protectors Coping strategies Self management Family History Disruptions in early years Environment stressors Environmentalprotectors External factors that cause the person increased stress. External sources of support.

14. Coping • Defined as: The active self generation of cognitive and behavioural procedures intended either to impact upon situation directly or to minimise the resultant distress. (Nuechterline and Dawson 1984) • Functions of coping: - To alter the source of stress - To regulate the emotional response (Lazarus et al 1985)

15. Coping • As part of the appraisal process in a stressful situation we examine our coping resources • The development of these coping strategies is affected by a number of factors including….....

16. Coping • Personality • Psychosocial development • Locus of Control - Is it my fault? - Was it fate? • Social Support - What relationships will help me fulfil my needs for coping • Implications for isolated groups such as people with mental health problems and the elderly (Shaw 1999)

17. Aims of Working with Coping Strategies • To foster feelings of self control and to help the client manage their own experiences and problems • To reduce distress and/or disability

18. Coping Styles • Detachment - Being independent from the event, not taking anything personally, not seeing the situation as a threat, keeping things into proportion • Rational Coping - looking for a reasonable response, using past experience to work out how to resolve a situation, problem solving

19. Coping Styles • Emotional Coping- Emotions dominate, taking frustrations out on other people, feeling overpowered and helpless • Avoidance Coping - Ignoring or denying the problem, hoping it will go away, thinking about something else and talking about it as little as possible.

20. Cognitive Strategies attention switching attention narrowing self-statement Think of something different Read silently Look for explanations of what's going on Behavioural Strategies increased activity levels increased social activity decreased social activity Talk to someone about the stressor Classification of Coping Strategies

21. Sensory Strategies Relaxation exercises Meditation Relax in bath or shower Hum or sing to self Classification of Coping Strategies

22. What is relapse prevention? • Service users, carers and MH workers identify each individuals early warning sings of relapse (relapse signature) • Agree and record in advance the nature of and timing of interventions if the signs return (relapse drill).

23. Benefits of Relapse Prevention • Collaborative process were service users are viewed as the experts of their experience. • Acknowledges personal strategies, skills and resources for self management. • Enables relapse to be predicted and interventions put in place to prevent or minimise negative impact on the individual. • Evidence based.

24. Stages of Relapse Prevention • Psycho-education • Two way process where the service user and practitioner work together to understand the individual nature of the persons experience. • Can involve the use of Stress Vulnerability Model to facilitate the process.

25. Stages of Relapse Prevention • Identification of Early Warning Signs (prodromal symptoms) • Highly diverse and vary from person to person. • General examples • Anxiety • Agitation • Mistrust • Specific behavioural patterns (idiosyncratic) • Eccentric clothing • Flamboyant hair styles

26. Identifying Early Warning Signs • Card sorting exercise • Client identifies early warning signs using cards • Arranges into early, middle, late and constant • Review information from both exercises with close family/ friends to identify gaps that service user finds difficult to remember. Limitations • Tendency to overlook EWS which are individual to that person. • Formulated in the MH workers language

27. Identifying Early Warning Signs • Timeline • A detailed account of the persons narrative of the events and experiences leading up to previous relapse. • Also identifies factors that have an impact on the onset of relapse eg external and internal stressors. • What might be the limitations/challenges of this approach?

28. Monitoring • Direct- Presence or absence of EWS are scored by the service user. • Indirect- Changes in circumstances, stressful life events or reoccurrence of circumstances which led to previous relapse.

29. Stages of Relapse Prevention • The development of a relapse drill • A 3 stage action plan developed collaboratively and focuses on client strengths, family and service resources • at each stage the relapse drill should consider 3 areas for intervention • Pathway to support. • Service interventions. • Personal coping strategies.

30. Emergency Contact Details

31. Challenges to Relapse Prevention • The service user may not agree with the perceptions of carers or MH workers. • Some people cope with MH problem by “sealing over” and are therefore unlikely to want to consider past experiences and the possibility of future relapse. • Many people experience difficulty with structuring their own reality (lack of insight) leading up to relapse. • Feelings of guilt in the service user if relapse still occurs.

32. Using the Stress Vulnerability Model to Assess and Plan Care • Use the case study to complete the SVM formulation. • Is their any other information you would need to assess this person. • How would you use this information to plan care.

33. References Lazarus, R.S. & Folkman, S. (1984). Stress, Appraisal and coping. New York: Springer. Nuechterlein, K. and Dawson, M. E. (1984) A Heuristic Vulnerability-Stress model of Schizophrenia Schizophrenia Bulletin, 10,300-12 Shaw, C. (1999) A framework from the study of coping illness behaviour and outcomes. Journal of Advanced Nursing 295 1246-1255 Zubin, J. and Spring, B. (1977) Vulnerability. A New View on Schizophrenia. Journal of Abnormal Psychology 86, 103-126.