VOL: 97, ISSUE: 30, PAGE NO: 40
Linda Khoo, RN, is a community psychiatric nurse at East Elmbridge Community Mental Health Team, Surrey
Siobhan Woollett, MSc (ClinPsycho), MA, is a chartered clinical psychologist at East Elmbridge Community Mental Health Team, SurreyLinda Khoo, RN, is a community psychiatric nurse at East Elmbridge Community Mental Health Team, Surrey
Early intervention with people who experience psychosis is widely detailed in the mental health literature (Birchwood et al, 1998). It is thought that early intervention, particularly within the critical two-year period (Carpenter and Strauss, 1991), can have serious implications in terms of preventing the impairments and disabilities that accompany psychosis.
Specific cognitive-behavioural therapy techniques can be helpful (Garety et al, 1994), but people who experience a first episode of psychosis need to appraise and adjust to their experience. Good early psychological adjustment can help to prevent serious consequences, such as depression, suicide and post-traumatic stress, and promote blame-free acceptance of illness (Birchwood and Tarrier, 1994) and a sense of mastery over it. An ongoing supportive therapeutic relationship aids early psychological adjustment and group work can be beneficial (Albiston, 1998), particularly in developing a sense of self and peer group and social contacts.
Setting up workshops
With this body of literature in mind, the Esher (now East Elmbridge) Community Mental Health Team became interested in early intervention. We began to collect data on all people newly diagnosed as having a psychotic episode. We also routinely offered them regular psychiatric outpatient appointments, individual psychological interventions, family work and day-service groups, if appropriate. There were eight young men on our list who had experienced one or two episodes of psychosis so we thought a group meeting would complement the interventions they were receiving.
Concurrently, interested clinicians in our community mental health trust began to meet and think about developing an early intervention service. Our proposed group meeting was discussed and this project was encouraged by senior clinicians and managers.
We asked care coordinators to discuss the idea with the eight clients identified before sending them invitations. They were asked to confirm their attendance, but we had to follow up individuals.
A number of the clients were working so we thought it appropriate to offer Saturday groups which, to reduce any stigma, we decided to call workshops. Two were held in a community mental health resource centre from 10am to 1pm on consecutive Saturday mornings. Five men agreed to attend but only three did. One had been admitted to hospital and the other did not show up.
Participants in the workshops
Of the three men who attended the workshops, two had experienced two episodes of psychosis and the other had had one. Two were working full time and one was seeking work. All felt they had made a good recovery. The average age was 24 and the average time in contact with services was a year. All had tertiary education and had used drugs. None reported current drug use.
Aims and formats of the workshops
The workshops had four aims:
- To allow participants to share experiences;
- To let them discuss the impact of being told that they had had a psychotic experience;
- To help them understand the experience;
- To discuss ways of remaining well.
The workshops were designed to have some structure but were informal enough to allow plenty of time for discussion. We used 'signs' cards (Table 1), similar to those described by Birchwood et al (2000), to generate discussion. These cards list possible experiences under three categories: thinking/perception, feelings and behaviours.
The first workshop session featured three parts:
- What does psychosis mean for you: the experience and the impact. Participants were invited to tell their stories and the 'signs' cards were used to encourage discussion on their experiences;
- Discussion on participants' understanding of their experiences. Brainstorming was used and we introduced more formal ideas, such as the medical model, the stress/vulnerability model and the role of drugs, into the discussion.
The second session focused on remaining well. We started by looking at what participants thought had helped them to get better and discussed the coping strategies they used. There was opportunity for them to share their concerns about difficulties recurring. New coping strategies, such as stress management, were introduced and relapse plans were discussed. We also helped to normalise their experiences by discussing how our brains can misinterpret information.
Themes emerging from the workshops
All participants felt their thoughts/feelings/ behaviours had been affected by psychosis. They described positive experiences, such as their senses seeming to be sharper because they felt they were being watched, as well as negative ones, such as a lack of concentration. All said how confused they were about what had happened. They had all used drugs and this appeared to help them bond.
Initially, the group talked about a positive outcome, such as feeling stronger as a person, which meant they did not regret the experience. But they also identified negative ones, such as losing a job, being watched by professionals, family and friends, feeling more reserved in relationships, having to take medication and recognising the effect on others.
All the participants believed that their bodies had developed a 'chemical imbalance' but that other factors, including taking drugs, a fast pace of life and lack of sleep, might also have had an impact. One saw his experience as a process of maturation.
All thought that being given time to recover and support were particularly important. They also agreed that psychiatric interventions had been helpful.
Anxiety and paranoia were seen as important potential signs of relapse. Other signs were being too analytical, feeling that they could not switch off their thoughts, feeling that they were in another world and not being able to sleep. Recognising individual symptoms of relapse was discussed.
Those strategies already used included stress management (managing self better), talking to others to get reassurance, help with thinking of alternatives and self-talk strategies. Sharing ideas aimed at coping was useful in this part of the session. The group facilitators also informed the group about simple cognitive strategies and stressed the need to be aware that feelings are not the same as facts and to know how to look for evidence for and against feelings/beliefs.
Feedback and evaluation were carried out through group discussion and by filling in an evaluation form that asked participants to identify which aspects of the workshops they found most useful and which they would like to change.
All the participants said that meeting others who had had a similar experience made them feel less isolated. They also appreciated the opportunity to share their experiences and ideas on how they coped and dealt with their problems and stress. The use of the 'signs' cards reminded them of particular symptoms they had experienced.
Conclusions and plans for the future
The participants found the workshops helpful. It was important that their experiences were seen as valid and they valued being able to reflect on this so that they could feel some sense of control over their psychotic experiences.
The three men who attended were ready to do this reflective work: they did not suffer ongoing psychotic experiences, they were compliant with medication and they were in regular contact with services. It is possible that people who had not reached this stage would not have agreed to attend.
Although the group was small, the experience and work were interesting and fruitful, and we felt that we had achieved our aims. We hope to update our register for people with newly diagnosed psychosis with a view to repeating these workshops.
Falloon et al (1998) suggest that ongoing psychosocial treatments that continue for at least two years have more lasting clinical and social effects and that a booster may be needed to support people through periods of serious stress. Mental health services need to plan for people who will require regular support and repeated interventions over months and years.