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Engaging young people in psychosis treatment - Coggle Diagram
Engaging young people in psychosis treatment
Why is it so important?
Without engagement, no treatment efficacy
Need to feel psychologically safe with accessing support offered
Early phase is critical
Birchwood et al. 1998
NHS England (2016)
Reducing DUP improves life chances
E.g. longer DUP means relationship with voices gets entrenched and social isolation becomes harder to roll back
Marshall et al. 2005 showed association with poorer recover and functioning
Increases SU and carer satisfation
Iyer et al. (2020): 88% of people at EI satisfied when told it would be extended rather than moving to regular care
Muir et al. (2009): young people felt +ve effects and carers v satisfied with Headspace, Australia
Puntis et al. 2020: review finds higher service satisfaction than TAU for early psychosis
EIP is more cost effective than standard care
e.g. NHS England, 2016
Clinical benefits
NHS England, 2016: better outcomes, lower unnatural mortality
How should we position ourselves?
Shouldn't be as hopeless as they may feel
Over-identification, over-empathising
Can be irritating because we're not going through what they are
May project fragility onto them - undermines recovery
but don't alienate them by being too positive
Scaffold
Trainee psychologists are often unwilling to exert power
But control is inherent in the situation
It's important to avoid misuse of power
Term 'patient' is problematic - they're not passive as traditional in healthcare
If they think they're a patient, not promoting their empowerment
If we think they're a patient, we're not recognising their resilience and that the means for recovery lies within them
Through empathy, understanding, hope and empowerment, helping them access support to live meaningful lives
SLaM's Five Commitments
To be caring, kind and polite
To be prompt and value your time
To take time and listen to you
To be honest and direct with you
To do what I say I’m going to do
Role of the therapist
Not an expert or teacher - has some ideas they think might be worth trying
Struggles with lots of the same stuff sometimes: we’re all trying to find ways of being the people we want to be
Can’t make pain and suffering go away (don't overpromise), but is committed to trying to make important changes together
Will try not to get downhearted when things are really difficult, or carried away when we’re making good progress
Genuinely cares
Attachment
Service = secure base
Safe haven where you can express your emotions, make sense of your distress, be looked after
Develop internal working model where you don't expect threat from others
Service approaches
Every staff member should be aware of this
Create physical and emotional environment conducive to secure attachment
Be aware of how your interactions, responses and attitudes interaction with this attachment relationship
Engage SUs in a way that recognises their individual attachment needs
Use clinical relationship to address some of those needs
Like limited reparenting in schema therapy
"Good parent"
Insecure and disorganised attachment patterns are almost universal in psychosis, making engagement difficult
Levin et al. (2020): systematic review showing positive correlation between insecure (esp anxious) attachment and paranoia in schizophrenia
van Bussel et al. (2021): SR & M-A showing poorer recovery in insecure (anxious and avoidance) attachment - because didn't engage?
But current relationship can supercede the existing one (Simpson & Rholes, 2012)
Davidson (2011) argues the preferred stance could be termed love
There can be a feeling of having lost personhood in psychosis
But without personhood, there's no-one to do the work of recovery
Therapist taking a dispassionate stance makes the SU feel like less of a person
Ideas of love
Agape - unconditional acceptance just because they're a fellow person
Karuna - offering compassion out of response for their dignity and shared humanity
Both offer basic validation - foundation from which to reclaim personhood
Offering agape = treating them like they're already a person
Discourages therapist from making decisions for them
Notice things they're already doing as proof of their personhood
Showing interest in their interests helps them recognise their strengths
Makes you more able to listen properly to the reasons they're acting as they are and help them reflect on that
Barriers
Emotional
If from black and minority ethnic community, low trust in certain service providers (NIMHE, 2003).
Might focus on coerced treatment, loss of freedom
So don't seek help early
-> becomes more severe
-> sectioning - so it's self-fulfilling
Stigma of defining self as “mentally ill” to access services (National Institute for Mental Health in England, 2004).
Services tend to define distress in terms of psychiatric disorders (NIMHE 2004)
Focuses on 'illness' - may not see self as 'ill'
Some communities may prefer the explanation of being possessed
Ignores that we're all on a continuum
SUs cite
Not being able to trust clinicians
Tindall et al., 2020 for EI services
Disagree with dianosis
Different goals to service's
Uncomfortable due to change of key clinician
Not feeling listened to, judged negatively
Practical
If low SES, not having the social resources to access more community-oriented interventions (Social Exclusion Unit 2004).
Lack of knowledge and awareness regarding available services (DoH, 2009)
A lot of the BAME community don't have a GP, no clear pathway to care
SUs cite
Not knowing who to ask for help
Tindall et al., 2020 for EI services
Changed circumstances
Cost (e.g. travel)
Recovery styles
Sealing over
Ignoring was ever unwell, attempt to preserve prior selfhood.
Downside: may not look after themselves in a different way to before - leaves them prone to relapse
Staring et al. 2011 - recovery style predicts remission
Integration
Ideal: can pursue recovery with identify holding both their well and having been unwell selves
Some also get consumed with themselves as an ‘ill person’, which also isn’t good.
Association of engagement with recovery style
Tait et al. (2003)
Some say poor engagement comes from poor insight
But little evidence of that
Alternatively, it's because of how they've psychologically adjusted to psychosis (recovery style, a coping strategy)
Longitudinal study of 50 pcpts over 6-month follow-up after acute treatment
Findings
Low engagement at 6 mo if sealing-over style at 3 mo
Psychotic symptoms and insight didn't predict engagement
Sealing-over wasn't associated with lack of insight
Pcpts moved from integrated to sealing-over from actute to 3-mo follow-up
Maybe gain insight, find it upsetting, and seal over
Limitations: urban population who were prone to relapse (since they'd had an acute episode) - not generalisable
Implications
Sealing is important to disengagement and treatment reluctance
Interventions should look at psychological defences, not insight
Can be naturalistic changes in recovery style over time
If develop an intergrating style, need to help them maintain it
Clinicians could tailor approach to recovery style to maximise engagement
Insight is less important, so don't need to wait for that to start helping them psychologically adjust to psychosis
Startup et al., 2005 - people who dropped out of CBTp engaged less and had sealing over RS
Strategies for overcoming barriers
Service level
Community outreach/service promotion
Mental health employee doesn't necessarily have position of trust - build relationships with those that do
Raise awareness e.g. session at local mosque that doesn't challenge religious explanations of psychosis
Visit agencies and organisations likely to come into contact with young people experiencing distress
e.g. Jisgaw in Ireland (McGorry et al. 2013)
Coproduction of services
Youthspace, UK - developed in consultation with young people
Raise awareness of early warning signs and how to seek help in different communities
Be prompt, flexible and effective in response
shape the service around the client's existing life
Individual level
See them where they’re most comfortable
e.g. : home, café at start
Confidentiality issues, but most important is to establish a relationship
Persistence, flexibility with appointments, tolerate missed ones
May take a while for SU to distinguish between service and the police
Involve family and support network early if possible
Find out SU's priorities and set shared, meaningful goals from the outset
Make sure therapy is in line with what they want to get out of it or they won't stay engaged
Tindall et al. (2020) - SUs say they disengage if not shared goals
Consider culture and diversity
High % people from BAME backgrounds in acute services
Preventative services struggle to reach some at risk groups
Cultural differences in how unusual experiences are understood
Need to adapt ways of working to build trust
Shouldn't have to abandon cultural interpretations to access help
Aim is to reduce distress, needn't impose a mental health explanation
Top tips
DO
Really, really listen – we can all tell the difference
Remember they're no different from you - chance!
Share your own experiences?
Can be a powerful to identify that it's normal to feel e.g. anxiety sometimes
Can be helpful to undermine the power differential in small ways
May stop them from taking a passive role
Treat people with the care and respect you’d want a family member of your own to receive
Focus your interaction around the client’s goals
Be open about not having all the answers
Communicate an appropriate hopefulness for, and belief in, the person you’re seeing
Recognise the importance of the moment, especially if it's their first contact with mental health services
It may take a lot to get to the appointment, they need to care about the outcome
DON'T
Let your own agenda become the focus of the interaction
Focus on whether you’re getting it right rather than the interaction
Session 1 with a new client
How would they like their life to change or be able to do differently?
What are their main obstacles?
Establish the role of therapy in this context
Why should they bother coming?
Relate psychological ideas to the problems they've outlined
Validates what they've described
Conceptualise a route back to their goals
Might pique interest
Engagement issues that might arise due to psychosis
Voice comments on sessions, tells the person not to tell therapist things
SU may feel suspicious of therapist or incorporate them into a delusion