Solution-Focused Therapy and First Episode Psychosis - Essay Example

Solution-Focused Therapy and First Episode Psychosis The of intervention and therapy of mental illness is a complicated theme that is approached with a variety of models. The use of each of these varies in efficacy and it is a matter of great importance to identify which works best. It is an important component of the success of future interventions. This paper will focus on the treatment of first episode psychosis. Early intervention and treatment of psychotic illness can reduce morbidity, speed up recovery, help provide better prognosis, preserve psychosocial skills, the preservation of family and social supports as well as the decreased need for hospitalization (Ovsiew, 2008, pp.197) One of the treatment techniques that is increasingly gaining attention these past few years is the “solution-focused therapy”. The corpus of literature on this subject, however, is still quite scarce. But some of the most important will be cited here. It is expected that deep insights will be gained from this type of therapy, particularly, from the explanations provided in the extant literature that cite empirical evidences. First Episode Psychosis General practitioners are recognized to have low index of suspicion for first episode psychosis and, what is worse is that they have little confidence in diagnosing it (Sandor and Courtenay, 2002, pp.976). Gleeson, Killackey and Krstev (2008, pp.224) also highlighted this problem by pointing out that a search of literature indicates a paucity of published research with this specific group of patients. This circumstance is disturbing because the inability to diagnose first episode psychosis will certainly lead to the aggravation of the disease. Without sufficient knowledge of its incidence, patients could be exposed to risks such as alcohol, drugs, adverse environment, among others factors that can contribute to its severity. Fortunately, there are few available that are already oriented in addressing this dilemma. For instance, there is the case of Helen Lester’s article (2001), 10-Minute Consultation: First Episode Psychosis. This is a comprehensive guide or framework for clinical practitioners to diagnose first episode psychosis. It outlined several issues that needed to be covered as well as a checklist of things that can be done in response. Lester’s work also provided a general idea of what first episode psychosis is, based on the list of symptoms identified. These include: irritability, losing concentration, depression, anxiety, feeling uneasy, constant tiredness, suspiciousness, rudeness and withdrawal from friends (Lester, pp.1408). The understanding of the signs is also augmented by familiarity with its causes. Lester, however, failed to discuss certain aspects in first episode psychosis that should have been included. For instance, she did not mention anything about hallucination as a conditional variable in her framework. Nonetheless, Lester’s guide could finally lead to an explanation why solution-focused therapy is successful. There are three main causes of psychosis. The first are the medical conditions that emerge as a consequence of some physical health disability or illness (Compton and Broussard, 2009, pp. 37). For instance, a brain tumor could induce hallucinations. Then, there is substance abuse. Drugs such medical steroids and medicines in the treatment of HIV/AIDS and Parkinson’s disease, among others can also lead to psychotic symptoms (Compton and Broussard, pp.39). Also, if an individual withdraws from a drug, he may experience psychosis. Finally, there are the psychiatric causes to psychosis. In the absence of medical or health condition and substance that induce psychosis, then the cause is considered psychiatric, wherein the symptoms are due to some brain disturbance (Compton and Broussard, pp.40). Larkin and Morrison demonstrated the dynamics behind first episode psychosis – its cause and effects – using the case of trauma (within the psychiatric classification) as a precondition to the mental illness. In this example, trauma may be one of several harrowing experiences and abuses that may be sexual, physical or emotional in nature. The trauma is considered to be at the heart – a mediating variable – that induces the first episode of psychosis (Larkin and Morrison, 2006, pp. 127). The argument is that such trauma results in “a complex array of interacting psychobiosocial factors including emotional dysfunction which arises as a result of disruption to a person’s developmental trajectory” (p. 127). This example, in addition to the previously cited causes, shows several variables that underpin first episode psychosis. First, it is revealed that the illness is a result of a complicated interplay of factors; hence, it could require a multi-dimensional approach of treatment. Secondly, it shows how the diagnosis and treatment of psychosis are anchored on individual experiences and needs. That is, what is true for one individual may not be true in the case of others. Or, in terms of treatment, an intervention may be effective in a patient but could fail in another. Appraisals, diagnoses, and treatments, hence, could differ according to the differing needs of patients. The available literature on psychosis collectively reveal how early diagnosis and treatment could prevent acute its incidence later on, particularly in the social disability aspect. This is best demonstrated in Frangou and Byrne’s (2000) work on schizophrenia. They found that sufferers who are treated in the early stages of the mental illness are more responsive to treatments. It is in this respect that the significance of solution-focused therapy for first episode psychosis is further highlighted. It plays an important role in the diagnosis and intervention of mental illnesses that could lead to a better opportunity to making a meaningful difference to the lives of psychotic patients. Solution-Focused Therapy Essentially, solution-focused therapy is an amalgamation of approaches that have been filtered out and developed based from what actually worked in the clinical practice. According to Rhodes and Jakes (2009, pp.1), it is not based from any grand or revolutionary new theory because it is simply “a way of working with people,” and that “it aims to solve problems by helping clients to describe situations in which problems does not occur, that is, when there are exceptions to the problem pattern.” This definition clearly shows its significance to the recognized notion that psychosis and its first episode have characteristics that are unique to the sufferer’s circumstance and experiences. This therapy involved strategic data gathering aligned with the objective of the model to solve a patient problem in the context of his or her own situation. Many observers consider this intervention method a positive approach. In a study by Franklin et al. (2011), it was found that there is a positive result in using the intervention approach in several aspects of treatment. For example, in a comparative analysis of a before and after solution-focused therapy involving medication regimen adherence, it was found that there was a more than threefold increase in the rate of medication adherence after the intervention (Franklin et al., pp.200). Patients are also found to favor this treatment as several studies such as those by Gingerich and Eisengart (2000) and Kim (2008) show that the average satisfaction level of patients that underwent or undergoing this treatment ranges from 70% to 85%. Solution-focused therapy shares some characteristics with other therapies and theoretical paradigms. For example, Corey (2012) stated that in some aspects of its therapeutic sessions when the therapist questions the client, it is similar to the Socratic method of inquiry. This is because there is no preconceived idea about how or in which direction the development of the stories goes and that the primary motivation is not to confront or challenge the patient’s story but, instead, to facilitate his narrative until an opportunity for new meaning is identified (Corey, pp.399). The not-knowing position is also a core element of the narrative therapeutic approaches (Robert and Watkins, 2009, pp.275). Conducting interviews and interest in doing brief treatments are also some of the similar aspects solution-based therapy and strategic therapy (Gubrium and Holstein 2002). The main distinctions of the solution-based approach from all related therapeutic models are the importance given to the solutions, goals, exceptions, resources, competency and relationships. Integrating Treatment Strategy Solution-focused therapy focuses on two treatment models: the first is the development of well-formed goals, with clients that are within their frame of reference; and, secondly, there is the development of solutions with the client based on “exceptions” (Zastrow, 2009, pp.524). The work of Berg and Miller (1992) investigating the effect of solution-focused therapy on alcoholics outlined several characteristics of what these goals are supposed to have. These offered a framework for clinicians in their attempt to devise the appropriate intervention according to the client profile. On the other hand, the “exceptions” critical in the development of solutions are the “occasions in clients’ lives when their problems could have occurred but did not” (Zastrow, p.525). The significance of these exceptions is recognized to lead to the variables that could be tapped and reinforced in order to create a proven solution to a problem. Unfortunately, research on first-episode psychosis is rare and more so, in the case of using solution-focused therapy in its treatment. So what are available are theoretical explanations, which could allow researchers and clinicians to develop their own model of treating first episode psychosis on a case to case. This researcher will attempt to do this as well based on the data gathered and cited in this paper. Say, a patient is undergoing therapy for first episode psychosis, diagnosed according to the Lester’s model but with few modifications such as the inclusion of questions regarding hallucinations in the patient’s interview. Then, a goal is set. The client does this and could be determined through scaling questions that are cited in the work of Metcalf (2011). Here, 10 means the patient don’t need to come back to see the therapist anymore and 1 means the patient feels like his life is in a desperate situation: these are analogous to ten, meaning the patient is making it and 1 means the client is in a desperate situation (p.302) The implication of this approach to goal setting is that it identifies goals, hopes and expectations. Using the solution-focused framework, a conversation will then be initiated so that solutions can be identified. If during the conversation it was revealed that one of the causes of first episode psychosis is a marital problem typified by incessant fighting with the spouse, then the therapist can facilitate the interview in order to identify “exceptions”. These will be the events when the couple was not fighting. The following questions, modified from Sharry’s (2007)original queries, may be included for this purpose: What went well with the relationship? What made the occasions go well? How did the patient help it go well? What skills, behavior or traits were involved to help it go well? When and how did the patient learn these skills and display the behaviors and traits? Based on the above questions, exceptions are identified and the therapist is finally able to devise an intervention strategy that is based on the reinforcement of the “exceptions” and the avoidance of the problem. This approach is supported by the research undertaken by Edwards and McGorry (2002), which found that the treatment of first episode psychosis must focus on reducing the cause and the symptoms within the patient’s psychosocial domains. The above example is a brief treatment but it typifies the conventional solution-focused therapy. This detail is attributed to the fact that the intervention has strong affinity with brief strategies. O’Connell (2005, pp.2) specifically identified this relationship with the work of Steve de Shazer and how both display common features such as “the view that yourself and others are essentially able”; the acceptance of the client’s definition of the problem; the therapist learning from the client; the avoidance of power struggle in the treatment process; and the objectification rather than the personalization of the client’s behavior, among others. The distinction from the more traditional forms of intervention and treatment is prominent here. The model is underpinned by a significant shift from the focus on expert to the cooperation between him and his patient. Here, the treatment does not rely on the problems or the deficiencies on the part of the patient. Instead, there is an emphasis to the exploration and development of competence and the achievement of knowledge from both the expert’s and the patient’s. This is critical in light of the few existing studies on first period psychosis that reveal relapse after treatment. Crow et al. (2001, pp.234), for example, found that by two years, following discharge after undergoing psychiatric treatment sustained by medications, 46 percent taking active drug treatment and 62 percent taking placebo had relapsed. The insight provided by this study highlighted the deficiencies in the traditional models of intervention and called for new approaches that can offer meaningful outcomes. Part of the efficacy of the solution-based approach in treating first episode psychosis is the requirement to include the patient in identifying the solutions to his or her illness. This is critical because during a first episode of psychosis people will have experienced different symptoms for different amounts of time under different circumstances but most importantly they will have appraised those symptoms and their diagnostic interpretation in different ways (Larkin and Morrison, p. 130). While the efficacy cannot be quantified as yet through empirical evidences, there are available studies using solution-focused therapy on related metal problems that demonstrate efficacies. For example, there is Nelson and Kelley’s (2001) work on implementing the therapy in couples group; Smock et al. (2008) and Pichots (2001) work on the use of solution-focused therapy in treating substance abuse; and, Pichot and Dolan’s (2003) study on how solution-focused therapy is effectively used in agency setting. This body of literature provides deep insights with regards to the actual implementation of the treatment model especially in the manner that it can inform the treatment of first episode psychosis. There was a study undertaken in 2004 by John Larsen that specifically examined the efficacy of solution-based treatment framework in first episode schizophrenia. It found that explanations for the experiences of first episode schizophrenics are crucial in its treatment (Larsen, pp.465). This is demonstrated in one of the interviews wherein a patient recovering from psychosis induced by love relationship stated: It was, kind of, something I was not able to deal with: “How do you stop being in love with somebody? How do you do that? It is not possible!.” And therefore, it was only the way I could do it, it was to arrange such a psychotic experience, you see. It effectively got me away from it [the love], you see, I was completely obsessed by it ‘the psychosis] (Larsen, pp.463). Solution-focused therapy is fundamental in the treatments as described by Larsen. It integrates in its strategy of intervention the patient-centric variables such as the ability of patients to create individual explanations about their psychotic experiences, which informs the therapists solution. Again, this framework is collaborative and the efficacy relies on the manner by which patients are involved, engaged and knows about their contribution to their treatment. This constitutes a meaningful dimension to addressing psychosis. It is like the learning, the understanding, the treatment and responsibility involved for initiatives taken are shared. This development addresses the problem posited by Rosenberg’s study (1984, pp.289), which stressed that the “defining feature of psychosis is the observer’s inability to take the role of the actor or to make successful attributions.” From the early years by which Rosenberg published his research, he already argued for a type of interactionist model of treatment. Fortunately, the solution-focused therapeutic approach answered this advocacy. It has been a product of development and would not have emerged without the experiences and the findings and positions revealed in studies undertaken by the likes of Rosenberg. Some Challenges Certainly, the popularity and the efficacy of the solution-focused therapy do not preclude some challenges that are entailed in this intervention model. For example, the theoretical approach appears easy to learn, but it may prove to be difficult to implement or integrate into practice. True enough, Metcalf (pp.303) was able to cite several problems, which include: 1) the tendency for the therapist to be drawn into the problem, making the treatment difficult to practice; and, 2) it is hard to avoid the tendency to categorize or classify people. It appears that these identified problems emerge from the fact of the therapists’ training. There is a potential of conflict from the conventional theories learned from previous practice that is informed by those theories. What this means is that limitations and problems could stem mainly from the skills and capabilities of individual practitioners. This can be further aggravated by the environment that has been designed. In solution-based approach, the therapist is provided with a great degree of power. In the intervention, he or she can decide what intervention to take and the degree that they are used. Conclusion Based on the solution-focused therapy framework – with its emphasis on goals and solutions – it is not hard to understand how it is recognized as effective and preferred by clinicians and experts in the field. This is primarily anchored on the mechanisms that the model is able to provide. The interventions designed, specific to the client’s circumstance and experiences, allow for changes and interventions that capitalize on the strength, goals, hope and expectations of the individuals being treated. As cited by this paper, the theoretical paradigm is not a complex or grand strategy that introduces some revolutionary or breakthrough principles in the sense that it is simple working model for clinicians. Unfortunately, there is a dearth of research on the subject, particularly in its implementation in the diagnosis and treatment of first episode psychosis. What this paper was able to identify was the theoretical relationship between the intervention model and the illness according to the studies undertaken investigating them separately. In this respect, there is a need for further research to inform the use of the model and avoid problems in the process. This is critical in light of the identified limitations of the intervention model. Also, it is expected that future studies could contribute to the development of a standardized framework that can guide therapists using it in their practice. References Berg, I. Kim. and Miller, Scott D., 1992. Working with the Problem Drinker: A Solution-Focused Approach. New York : W.W. Norton. Compton, M. and Broussard, B., 2009. The First Episode of Psychosis: A Guide for Patients and Their Families. New York: Oxford University Press. Corey, G 2012., Theory and Practice of Counseling and Psychotherapy. New York: Cengage Learning. Crow, T.J., Curtis, D., Frangou, S., and Byrne, P., 2001. 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