- Hi. This is Dr. David Shern from the National Association
of State Mental Health Program Directors
and I'd like to welcome you to the third in a series of videos
that we've produced with our colleagues
Dr. Jessica Pollard and Dr. Michael Hoge
at Yale University
on issues involved in the transition of individuals
from coordinated specialty care, specialty programs
for persons experiencing first episode psychosis
at the ongoing supportive community care.
Today we're gonna talk about specific recommendations
for continuing care.
This is part of a series of technical assistance materials
that we've developed over the last four years
with the sponsorship of the Substance Abuse
and Mental Health Services Administration, SAMSHA.
And in the lower left corner of the title slide,
you can see reference to a website that contains
all of the information that we have developed
in this technical assistance portfolio.
So today, Dr. Jessica Pollard will be giving our presentation
with regard to best practices in continuing care
after intervention for psychosis,
recommendations for continuing care.
Jessica?
DR. JESSICA POLLARD: And if you're looking for an overview
or refresher on psychosis,
a review of the evidence base for early intervention,
or a description of the transition process,
please do refer back to webinars one and two.
"The views, opinions, and content
expressed in this presentation
do not necessarily reflect the views, opinions, or policies
of the Center for Mental Health Services,
the Substance Abuse and Mental Health Services Administration,
or the US Department of Health and Human Services."
So as someone who is receiving clients
after an early intervention program,
you are supporting them on staying
and on a positive trajectory.
Continuing care providers may not have access
to all of the services or training
around early intervention
and that clients were receiving in CSC,
but are very likely to be able to maintain
the overall treatment approach and values
of these kinds of programs in order to ensure continuity,
ease the transition, and support ongoing recovery.
So, keeping a consistent approach in values
can make a big difference.
And we wanna support and encourage clients
to connect with resources or services
like those they found helpful in CSC,
even if those aren't services that you offer in your program.
So, for example, if family support and psychoeducation
isn't something that your agency offers,
the families could be referred to a local chapter of NAMI,
or other kinds of family support services,
or if you don't have support of employment in your agency,
maybe the bureau of rehabilitation services
in your community could be a resource.
And in keeping in line with the CSC model,
continuing care providers can coordinate services
as much as possible to maintain those gains.
And a note of caution that can sometimes happen
during a transition,
the continuing care provider may see a client
who's relatively remitted,
or their symptoms of psychosis are not evident at that time,
and be tempted to change the diagnosis
because they aren't seeing those symptoms of psychosis
at present.
So, we wanna caution that that can be destabilizing
by discontinuing the needed treatments for psychosis,
so, of course, if we changed the diagnosis away from psychosis,
you would be changing the treatment as well.
So, CSC providers are happy to provide a rationale
for the psychotic disorder diagnosis
that they arrived at over time, or the background of
how that diagnosis was made in the first place.
So even if the symptoms aren't present currently,
they may have been present in the past
or they were present in the past.
Let's talk about best practices for clients
coming from early intervention programs.
So we really wanna focus on what the client has identified
as being important to them,
so what their goals are
usually going to revolve around functioning,
so going back to work or school,
having relationships, living independently,
and those are the things that we wanna focus on
as providers in treatment planning.
And we wanna tie our discussion of potential treatments
to those goals and priorities
rather than focus on symptoms alone.
So you may find that clients from early intervention programs
are not that interested in talking about symptoms
or difficulties,
but you'll really be able to connect with them
if you interest them and gear treatment toward the things
that are important to them
and what they're functional goals are.
And we wanna ensure that the treatment minimally interferes
with the person's functioning or their areas of wellness.
So that can be things like making sure
the medications that we prescribed
aren't sedating the person to the point
that it's interfering with their ability
to go to school, for example.
So that kind of ties into the next point
about minimum effective dosing of medication.
So working with clients to really fine-tune
what's the lowest possible dose we can get away with
so that symptoms are at a tolerable level
but that the person is also not experiencing interference
in their functioning from the medication
or unwanted side effects.
We really wanna discourage any rationale
for discontinuing medications entirely,
so making them as palatable as possible.
And if you're not already, you wanna make sure
that you become as knowledgeable as possible
about psychotic disorders
and the treatment of psychotic disorders.
So, sometimes, continuing care providers,
if they don't have a lot of experience with psychosis,
might be anxious about working with these individuals
or feel unsure of their skill sets,
but there's a lot of information available to you
and readily accessible,
so that you can feel more knowledgeable and confident
that you know what to expect when it comes to psychosis,
which will put clients and families at ease.
And a lot of your existing skill sets
around evidence-based practices
are applicable to psychosis,
so as we described in earlier webinar,
CBT, multi-family group,
motivational enhancement therapy,
these are skills that you likely already possess
as a continuing care provider and that you can use them
with your clients with psychosis,
once you're comfortable and knowledgeable about psychosis.
So we wanna make sure that we're really conveying comfort with
and acceptance of psychosis,
so our clients are often really sensitive to this
in terms of nonverbal cues and tone.
If you're appearing anxious and uncomfortable,
then that's going to make it harder for that client
to engage with you and to build rapport.
So a lot of clients will notice tension or apprehension,
and on the flip side,
it's comforting to clients and families
when you can normalize psychosis and know what to expect.
So these are just a couple of points to keep in mind.
They're kind of basic but important skills.
And the other tension to be wrestling with
or to keep in mind is this maintenance of optimism
or expressing optimism about recovery
and keeping a very positive outlook
since the evidence for this is pretty solid
that people can recover from psychosis
but at the same time, we have to pay attention to
and be very mindful of risks,
both of in terms of harm to self or others and relapse.
So it doesn't mean we're constantly talking about it
or that this needs more focusing on,
but it's something we're keeping eye on
and paying attention to.
And then we conduct risk assessments as necessary,
at the same time,
we're maintaining that hopeful outlook.
So, on a related note, it's really important
that we're able to distinguish symptoms of psychosis from risk,
and that can be a common pitfall
of equating active psychotic symptoms
with the need for hospitalization.
And, you know, of course there are times
when there is actual risk, such as,
the person experiences an increase in suicidal ideation,
or perhaps, they are experiencing a paranoid delusion
that is putting them at increased risk
of having a confrontation or altercation with someone.
Those would be times that we of course wanna pay attention
to risk and be assessing the need
for potential increased intensity of services
or hospitalization.
But that's different than seeing things
like auditory hallucinations or hearing voices
as a reason to go to the hospital.
So keeping in mind, symptoms of psychosis might be present,
but that does not necessarily mean
that it's an increased risk for harm.
And the focus on long term engagement,
keeping that in the forefront, and by that I mean,
making sure that we're being patient with clients
in order to get their buy-in on decisions or interventions
rather than trying to get a quick change or decision,
but may be doing that in such a way
that pressures the client
and makes them more likely to disengage from treatment.
So we often have plans or goals
that we need to take our time
in order to achieve those collaboratively.
So talking small steps, being patient,
and recognizing we're in it for the long haul.
Skills in motivational enhancement therapy
can be really helpful in this endeavor;
so it's applicable to making lots of kinds of changes,
or accepting treatment in psychosis,
such as taking medication or making a behavioral change.
So if you have those skills that you use for substance abuse
or other conditions,
those can be really helpful here as well.
And we wanna strike a balance of making recommendations
as treatment providers,
genuinely sharing our perspective,
balancing that out with listening to
and valuing the client's perspective
and figuring out a way to find middle ground if necessary.
So it's that balance of not necessarily just agreeing with
everything that that client have expressed for,
ideas, or preferences.
We, of course, have our own recommendations as well,
but really making sure we're striking a balance
between those two things.
We wanna strike a balance of including families
or other support systems in the client's social circle
who can be used for varied barometers
for relapse prevention.
So they may notice those early warning signs
of a psychotic episode or relapse
that occur outside of the office.
And they can also really support carrying out treatment goals
that we're working on with the client.
And we're balancing that out
with the developmentally appropriate desire
to be independent for this age group.
So we also wanna empower clients
and sometimes that limits our boundaries
around the family or social support as appropriate.
And as much as possible, we want to reach out to clients
who aren't coming in or who are not fully engaged.
Maybe they need reminders to come in,
sending encouraging messages
about wanting to make progress on treatment goals
rather than sending out messages about discharging a client
if they're not coming in,
as the sole communication for those clients
who aren't keeping appointments.
So within the bounds of your agency's policy,
you might be able to reach them in various ways
like doing a home visit, or other ways
that you might overcome things around disengagement
or disorganization.
So, if you can be flexible about seeing a client
who may have a hard time with keeping a set appointment time,
if you have open access hours, for examples.
And unlike in chronic psychosis
where the cardiovascular risk factors
are significantly higher than their same age peers,
in the early stages,
our early intervention clients are on par with their peers.
So this is a really important time for prevention
in order to avoid the mortality morbidity issues
that we see in psychotic disorders.
So keeping this issue on the table
in terms of weight gain or metabolic syndrome
and intervening as appropriate.
So encouraging healthy lifestyles,
if you can offer interventions around that,
around diet and exercise;
and if the person is gaining weight,
or showing signs of metabolic syndrome,
consider switching their medication
or adding on an appropriate treatment such as Metformin.
One of the most important recommendations
would be to monitor for psychosis relapse,
that, as optimistic as we're gonna continue to be
about recovery, we also wanna make sure
we're on top of preventing future episodes of psychosis
since those are absolutely possible,
particularly under times of increased stress.
So we wanna make sure that we know
what our clients' individual early warning signs are,
so those are the signs and symptoms
that led up to their first episode
and any subsequent episodes that they had.
And the clients and families are often familiar
and knowledgeable with these signs and symptoms
and can help fill you in on what those are.
The early intervention team or CSC,
likely gathered this information and can share it with you.
It's particularly helpful if we know
the very early warning signs,
so not the signs that someone's right on that edge
but kind of maybe, on their way to a psychotic episode,
so we wanna look out for smoke rather than flames.
So clients can have their own generated definition of wellness
that can be a really important part
of their relapse prevention plan
and kind of, move out of the negative frame
that sometimes that focus on symptoms alone
can bring with it.
So for example,
you know, what are the signs that the client knows
that they're doing well?
How do they operationalize that, how they objectively define it,
so that we can monitor and quickly catch if the person
is not meeting their definition of wellness.
So that may be things like
how many hours of sleep do they get per night;
are they getting good grades in school;
how many hours are they spending outside of their home
or their bedroom?
And we really wanna work with clients and families
as much as possible on this monitoring,
and the earlier we catch it,
the more effective it's likely to be.
So, along with those early warning signs,
knowing when we should expect to see
those early warning signs,
so what are the clients' individual stressors
or what are the things that are most likely
to kind of exceed their coping capacity?
And of course, that varies from individual to individual.
And then, what do we do if we notice
those early warning signs of a potential relapse?
So there are a lot of things we can do.
We can temporarily increase,
or if we've discontinued medication,
we can re-initiate the anti-psychotic medication,
we can see clients more often,
we can increase the intensity of services,
we can re-involve families,
or increase the amount that we're involving families
in treatment, in order to help us
do things like increase the amount we're practicing
and using coping skills.
So we're reviewing, you know, what are the things
that have been helpful for the client in the past
to cope with symptoms or to cope with stressors,
and then making sure that those are being practiced
more often or that we're re-initiating those.
And then, what can we do about the stressors
that are likely precipitating an increase
in early warning signs?
So clients and families or other support system
can be really helpful in identifying
what did cause this increase in stress
and then what could be done about it.
So if the client and family hasn't already,
then explicitly taught problem solving skills,
that's another way that we can be helpful,
practicing those or teaching those skills.
So, to summarize, psychotic disorders
can have a tremendous impact on our clients.
They can make it very difficult to function
and even increase mortality compared to peers.
However, early intervention can dramatically improve
the person's trajectory.
And early intervention programs like coordinated specialty care
put a lot of time and effort
into maximizing client functioning
and avoiding psychosis relapse.
So we really wanna work with continuing care providers
to make sure that those gains are maintained,
and that a lot of the skills
that continuing care providers already have
can be used in a modified form
to work with early intervention clients effectively.
So really understanding the values of
early intervention and continuing those.
And your work as a continuing care provider is vital
to the success of early intervention clients,
so they made a lot of progress
and we really wanna keep them on that track.
And there is, thankfully now, a wealth of resources
that are available to you to learn more about psychosis
and evidence-based treatments.
And many of those resources
are even free and available online.
And this is by no means an exhaustive list,
but here are some of the resources that we recommend
for learning more about intervention with psychosis.
There are webinars on the Stanford and NASMHPD website
that are listed here
that can be particularly helpful to make sure you learn
or brush up on shared decision-making skills.
For prescribers, there's a specific tool
that SAMSHA has developed that can be really helpful.
And if you don't already have interventions that you use
for improving physical health, this is a great resource,
specifically for young people with psychosis
and physical health.
And then, in general, there are lots of resources
for evidence-based practices for schizophrenia,
but here are two that we particularly recommend.