The organization of treatment for psychosis

Because people with one disease entity (schizophrenia) do not exist, only persons with experience with psychosis, with very different background, very different symptoms and very different needs, therapy for people with psychosis must be need adapted. So for instance one person will benefit most from psychodynamic therapy another person from paid work. Also the needs of a person can change overtime. Therapy can be short sometimes but must be longtime if needed, without changes of therapist caused by the system. And a psychosis affects not only a person but also family and friends. And good relationships with family and friends is good for recovery. Therefore most effective programs are need adapted, offer continuity of care and include also family work. In this page you find examples.

An example: Our stories - Living and Coping with Schizophrenia in India (short version; general) COPSI (COmmunity care for People with Schizophrenia in India) project,

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The opinion of ISPS

 

The ISPS Charter of Good Practice in Psychological Therapies for People Experiencing Psychosis

Need Adapted treatment model

The needadapted treatment: Schizophrenia: Its Origins and Need-Adapted Treatment Paperback – May 31, 1997 Yrjö O. Alanen 

In this book you find memorable case vignettes along with research findings and is recommended for clinicians, students, teachers of mental health and those in public policy involved in creating effective treatment methods.

Need-adapted treatment of new schizophrenic patients: experiences and results of the Turku Project., Alanen YO1Lehtinen KRäkköläinen VAaltonen J. This article describes a psychotherapeutically oriented approach to schizophrenia developed especially to meet the needs of the community psychiatric field. Because of the heterogeneous nature of the schizophrenic psychoses, the authors emphasize that these patients should always be treated based on case-specific premises. The main principles of the need-adapted approach are: 1. The therapeutic activities are planned and carried out flexibly and individually in each case so that they meet the real and changing needs of the patients as well as of their family members. 2. Examination and treatment are dominated by a psychotherapeutic attitude. 3. The different therapeutic activities should support and not impair each other. 4. The process quality of therapy is clearly perceived. A family-centred initiation of the treatment is especially emphasized for both diagnostic and therapeutic reasons. The positive experiences of this led the Finnish national programme for the treatment and rehabilitation of schizophrenic patients to recommend the establishment of family- and environment-oriented acute psychosis teams (APT) in the mental health districts. In later phases of treatment, the significance of individual psychotherapy is increased. The preliminary results of the approach are presented and compared with an earlier sample of patients. see first page Pdf

Evidence, of needadapted treatmentmodel

Need-adapted treatment of schizophrenia: a five-year follow-up study from the Turku project., Lehtinen K The five-year follow-up results of 28 first-contact schizophrenic patients are compared with an older patient series of 53 patients from the same district. The treatment of the new series followed the principles of the need-adapted model. The emphasis was on immediate initial crisis-oriented family interventions. The treatment of the old series followed psychodynamic principles with an emphasis on individual and milieu therapy. The patients in the new group manage better with half the number of hospital days and less outpatient treatment. The differences are most clear in men. The crisis orientation caused failure in sustaining longer treatment relationships. This was harmful for patients and families with a more chronic development. In future, better continuity of treatment must be emphasized. see first page Pdf

 

Towards Need-Specific Treatment of Schizophrenic Psychoses: A Study of the Development and the Results of a Global Psychotherapeutic Approach to Psychoses of the Schizophrenia Group in Turku, Finland (Google eBoek)Yrjö O. AlanenViljo RäkköläinenJuhani LaaksoRiita RasimusAnne Kaljonen 

Open dialogue model

In Finland, family with a psychotic person are visited from the very first day, while everybody including the psychotic person tells about his or her experiences, the meaning of psychosis becomes clear. OPEN DIALOGUE: 74-minute documentary film on the Western Lapland Open Dialogue Project, the program presently getting the best results in the developed world for first-break psychosis -- approximately 85% full recovery, a far majority off antipsychotic medication. Filmed in Finland. Directed by Daniel Mackler. 

Evidence of open dialogue model

Five-year experience of first-episode nonaffective psychosis in open-dialogue approach: Treatment principles, follow-up outcomes, and two case Studies Jaakko Seikkula , Jukka Aaltonen , Birgittu Alakare , Kauko Haarakangas , Jyrki Kera¨ Nen , & Klaus Lehtinen, Psychotherapy Research, March 2006; 16(2): 214/228  Abstract: The open dialogue (OD) family and network approach aims at treating psychotic patients in their homes. The treatment involves the patient’s social network and starts within 24 hr after contact. Responsibility for the entire treatment process rests with the same team in both inpatient and outpatient settings. The general aim is to generate dialogue with the family to construct words for the experiences that occur when psychotic symptoms exist. In the Finnish Western Lapland a historical comparison of 5-year follow-ups of two groups of first-episode nonaffective psychotic patients were compared, one before (API group; n/33) and the other during (ODAP group; n/42) the fully developed phase of using OD approach in all cases. In the ODAP group, the mean duration of untreated psychosis had declined to 3.3 months (p/.069). The ODAP group had both fewer hospital days and fewer family meetings (p B/.001). Nonetheless, no significant differences emerged in the 5-year treatment outcomes. In the ODAP group, 82% did not have any residual psychotic symptoms, 86% had returned to their studies or a full-time job, and 14% were on disability allowance. Seventeen percent had relapsed during the first 2 years and 19% during the next 3 years. Twenty nine percent had used neuroleptic medication in some phase of the treatment. Two cases from both periods are presented to illustrate the approach.

Resource Group Assertive Community Treatment

Involving clients and their relatives and friends in psychiatric care: Case managers' experiences of training in resource group assertive community treatment, Tommy Nordén, Anders Eriksson,Anette Kjellgren and Torsten Norlander2 The purpose of this project was to do a qualitative study of an integrated and flexible ACT model, the Resource Group Assertive Community Treatment (RACT), as seen from the perspective of case managers in training. The resource group normally consists of the client, the case manager and other available personnel in the medical and support areas, as well as family members. Nineteen theses were randomly chosen from a set of 80 theses written by a group of Swedish trainee case managers. The exams were conducted as case studies and concerned 19 clients with psychotic problems, 11 men and 8 women. “The Empirical Phenomenological Psychological Method” was used in the analysis, which generated five overarching themes: (a) the RACT program; (b) the resource group; (c) the empowerment of the client; (d) progress in treatment; and (e) the case manager. These together constituted a “therapeutic circle,” in which methods and tools used within the RACT made it possible for the resource group to empower the clients who, as a result, experienced progress with treatment, during which the case manager was the unifying and connecting link. 

The Clinical Strategies Implementation Scale Revised (CSI-R). Fidelity Assessment of Resource Group Assertive Community Treatment

 

The Clinical Strategies Implementation scale (CSI) was originally designed to be used by external reviewers in order to measure the extent to which evidence-based strategies had been implemented in the treatment of persons with schizophrenia spectrum disorders according to Resource-group Assertive Community Treatment (RACT). The present investigation had two aims: 1) to conduct a revision of CSI and to examine the revised instrument (CSI-R) in terms of interrater reliability (Study I); 2) to compare assessments of CSI-R made by experienced assessors with assessments made by students in case management (Study II) in order to determine whether the instrument has validity even when more inexperienced persons are using it. In Study I six raters, who took part in 12 to 15 cases from three outpatient community mental health teams, participated. Results indicated that internal consistency of the CSI-R was strong (alpha = 0.89) as well as correlations between individual raters’ (r between 0.80-0.98). In Study II 91 newly trained RACT praxis trainees participated. Each of them followed one case for eighteen months, i.e., the client which they had been assigned during training (n = 91). The five external auditors in the education program then independently assessed the 91 cases with the CSI-R. Results showed significant correlations between experts and trainees (rho = 0.68, p < 0.001). The conclusion was that the new CSI-R scale was shown to have acceptable internal consistency and interrater reliability and may be used for continuous self-monitoring of praxis fidelity by inexperienced raters. 

Evidence of Resource Group Assertive Community Treatment,

Resource Group Assertive Community Treatment (RACT) as a Tool of Empowerment for Clients with Severe Mental Illness: A Meta-Analysis, Tommy Nordén,  Ulf Malm,  and Torsten Norlander The aim of the current meta-analysis was to explore the effectiveness of the method here labeled Resource Group Assertive Community Treatment (RACT) for clients with psychiatric diagnoses as compared to standard care during the period 2001 – 2011. Included in the meta-analysis were 17 studies comprising a total of 2263 clients, 1291 men and 972 women, with a weighted mean age of 45.44 years. The diagnoses of 86 % of the clients were within the psychotic spectrum while 14 % had other psychiatric diagnoses. There were six randomized controlled trials and eleven observational studies. The studies spanned between 12 and 60 months, and 10 of them lasted 24 months. The results indicated a large effect-size for the ”grand total measure” (Cohen´s d = 0.80). The study comprised three outcome variables: Symptoms, Functioning, and Well-being. With regard to Symptoms, a medium effect for both randomized controlled trials and non-randomized studies was found, whereas Functioning showed large effects for both types of design. Concerning Well-being both large and medium effects were evident. The conclusions of the meta-analysis were that the treatment of clients with Resource Group Assertive Community Treatment yields positive effects for clients with psychoses and that the method may be of use for clients within the entire psychiatric spectrum. 

Websites

In Parachute NYC, Mobile Treatment Teams provide integrated care that is adapted specifically to a person’s needs and allows them to recover in settings that are comfortable and familiar. Trained staff actively engage family and friends to create a network that supports recovery. Crisis Respite Centers offer warm, safe and supportive home like places to rest and recover for up to two weeks when the person needs a type of support that cannot be provided at home. Peers with special training operate a confidential Support Line that offers support for those going through difficult times.The program employs specially trained peer specialists in tandem with behavioral health professionals to work with a person move towards recovery. 

Open dialogue UK website

 Open Dialogue UK has been established to promote the development of the Open Dialogue approach in the UK.  On this site you will be able to find out about our clinical services and a UK Open Dialogue Training Programme for NHS teams and independent practitioners, commencing in London in April 2015. If you are interested in us running a seminar in your area, then please see this page.  In time you will be able to read articles about the Open Dialogue approach on this website. 

Implementation of evidence based therapy

A Two-Year Multidisciplinary Training Program for the Frontline Workforce in Community Treatment ofSevere Mental Illness, Torleif Ruud, M.D., Ph.D., Karin Blix Flage, R.N., Ole-Bjørn Kolbjørnsrud, M.D., Gunnar Brox Haugen, R.N.,Tore Sørlie, M.D., Ph.D. 

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The ISPS Journal Psychosis accepts personal and institutional subscriptions. All Individual Members of ISPS and members of regional ISPS groups receive quarterly issues of the journal as a membership benefit.

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