Psycho-social Interventions with Psychosis - Essay Example

Introduction Psychosis is a generic phenomenon referring to the mental condition during which an individual senses a detachment from reality and realistic events around. As described by Stedman's Medical Dictionary, psychosis can be defined as a severe mental disorder characterized by distorted personality along with loss of contact with reality in association with decline in normal social performance. It may occur with or without any evident organic damage. Individuals suffering from psychosis may report having hallucinations or delusions with split personality and disorganized communicative signals along with shambolic thinking pattern. This is also accompanied by reduced insight along with exhibited bizarre nature and difficulty in social communication as well as prominent impairment is observed while carrying out daily activities. A wide array of nervous system stressors can result in a psychotic reaction both at organic as well as functional level. However, the first line treatment for psychosis is generally associated with the administration of antipsychotic drugs and in some cases hospitalization, but there is increasing research evidence that suggests cognitive therapy; family therapy can be effective in the management of psychotic symptoms. This paper critically reviews on psychological intervention with patients affected by serious and prolonged mental disorders and the strengths and weaknesses associated with such types of therapeutic interventions. Psychosis Psychosis is a mental state defining a group of mental disorders come into one singe head in psychiatry and it is characterized by certain common fundamental factors such as hallucinations or sensation of non-existent objects or phenomenon; delusions or possessing beliefs not based on reality; thought insertion, withdrawal, thought blocking, thought broadcasting lack of insight or being unable to understand the wrongs in the thinking or activity patterns. However, there are number of controversies associated with the psychiatric classification of psychosis, but usually the most common disorders come under the general title of psychoses are as follows: - Schizophrenia - Schizoaffective disorder - Maniac Depression (Bipolar Disorder) - Mania - Delusion (Paranoid) Disorder - Psychotic Depression Although these disorders differ in their symptoms but they consist of a common parameter that the individual suffering from any of the disease does not experience reality as most of the other people in general. Sample Case Study The patient is a female of 18 years doing graduation in a co-education college. She was brought to the clinic by her mother and sister for lack of sleep, verbal and physical aggressiveness, suspicion that the male faculty members in her college are writing love letters to her and making obscene gestures during the lecture and the fear of becoming a male. She had the habit of peeping into the bathroom when her mother takes bath. Sometimes she blamed her mother of appearing nude before her. Her elder sister and elder brother had innocuous relationship. She did not have any intimate relationship with the member of the same sex. The family disapproved of her friendship with boys of questionable character. Therapeutic Strategies Suggested The patient mentioned in the case study is suffering from paranoid schizophrenia. In the initial phase of the treatment, she was suggested to undergo neuroleptic pharmacotherapy especially antipsychotic drugs. The medication has been found to be effectual in treating the 'positive symptoms' of the disease, the treatment of 'negative symptoms' has not very yet found to be very successful. Later on she was suggested to undergo psychotherapeutic interventions like reality-oriented individual therapy so that she could be able to cope up with stressful thoughts and events encountered which eventually reduce the risk for relapse, cognitive-behavioural approach helps in monitoring and changing the negative patterns of thoughts and behaviours in ways to make her able to regulate irrational thoughts and feelings as well as psychosocial therapy such as rehabilitation programme, family therapy in order to enhance her distorted social functioning, coping strategies and problem-solving skills. The Effect of Individual Psychotherapeutic Intervention The recent advancement has been observed in the pharmacological management of the psychoses; however, several studies suggest that the prognosis of affective disorder such as psychoses is not up to the mark especially in the cases of relapse (Wiersma et al, 1998; Robinson et al, 1999; Ohmori et al, 1999). Near about 30% of the patients from general population respond poorly to the pharmacological medication with an evidence of persistent symptoms of functional impairment (Kane, 1988). Frangou and Murray (2000) argued that the schizophrenia patients received only pharmacological treatment has shown a limited or insignificant enhancement in social functioning. The implementation of psychiatry has become increasingly categorised into aficionados of the psychodynamic and bio-physiological approaches (Fenton, 2000). There are different debatable perspectives raised in comparing the value of comprehensive psychotherapeutic intervention versus medication. However, the past decades has been shifted away from this ideological disputation agreeing that no individual approach could be beneficial in treating schizophrenia, a significant form of psychosis. However, neuroleptic medications are the mainstay in treating psychosis; around 25% - 50% of the victims carry on experiencing unrelenting and distressing symptoms (Garety et al, 2000). Despite going through thorough medicinal administration, the patients may subject to periodic relapses (Hogarty & Ulrich, 1998). The adherence to medicinal regime may decline due to the unpleasant and disabling side-effects. These primarily prompted many researchers to focus on complementary treatment for psychosis, but yet the comparison between pharmacological studies and psychotherapeutic studies prevailing as the treatment of psychosis describes that there needs to conduct more researches in this area with psychotherapeutic interventions. Fenton (2000) suggests both a thorough historical account of the theory of individual psychotherapy for schizophrenia and a literature review suggesting its efficacy. He also suggests that there is no individual component that can be accounted for the successful treatment of schizophrenia and an inflexible adherence to an individual technique may lead to the victim in non-beneficial as well as problematic condition (Fenton & McGlashan, 2000). However, researchers have not found any significant correlation among the positive effect derived from the administration of psychodynamic, insight-oriented therapeutic intervention whatsoever (Malmberg & Fenton, 2002). Rather they suggest that the possibility of analysing negative effect due to the application of such therapeutic intervention has been ruled out. Moreover, Fenton (2000) argues that there is little evidence found in the support of the beneficial effect derived from administrating psychodynamic therapy over medication. In the empirical evidence, it has been found that the individuals treated with medication have been shown superior outcomes in comparison with the individuals treated under psychodynamic therapy. Rather it has been found correlated with the patients post-therapeutic impaired functioning as a whole. On the other hand, psychosocial rehabilitation provides significant add-ons to pharmacotherapy (Bachrach, 2000) which is proven to be beneficial in treating patients suffering from schizophrenia (Bachrach, 1992; Bachrach 1996). The primary objective of this intervention is to facilitate the patients to accomplish the highest possible quality of life by means of regaining the physical, emotional, social and intellectual skills needed to accommodate within the community (Anthony, 1988). However, potential researchers have not yet been conducted in the cases of the individuals with a first episode of psychosis (Huxley, 2000). Cognitive Behavioural & Psychosocial Therapeutic Intervention for Psychosis Cognitive-behavioural approach has been found effective in treating neurotic disorders like anxiety and depression. Hence its application has been increasingly found effective in varied regimes of psychosomatic disorders (Haddock et al, 1998) as well as in the area of treating psychosis. According to Eells (2000), the psychodynamic approach had been contributed largely to the disappointing outcomes which eventually enhance the contribution of comprehensive implementation of psychosocial intervention on psychosis assuming diathesis-stress model in association with the application of pharmacology. Researchers suggest that there is growing evidence that confirm psychotherapeutic interventions such as cognitive-behavioural approach and psychosocial intervention have provided proven benefit and need to undergo extensive evaluation in non-experimental settings (Thornicroft & Susser, 2001). Tarrier et al (1998a) proposed an investigation for finding out the important improvements in psychotic symptoms and relapse rate intervened by cognitive-behavioural therapeutic interventions. The study involved cognitive therapeutic assessment as well as supportive counselling to conventional care procedure. The cognitive-behavioural therapeutic intervention included 20 hours of therapeutic session for 10-week period by trained therapists. Both of the groups have been chosen as experienced symptoms for a minimum of past six months. Findings suggest that there is a 50% decline in symptoms along with declined days of staying in hospitals for the control group individuals, assessing which the researchers concluded that cognitive-behavioural therapeutic intervention provided a significant benefit over the conventional one and had been found as potentially beneficial. However, Curtis (1999) argued that there were no significant differences between the administrations of cognitive-behavioural therapy over conventional counselling with routine care. A follow-up study conducted by Tarrier et al (1999) suggests the potential benefit of cognitive-behavioural therapy over individual supportive counselling especially in the area of reducing positive symptoms of schizophrenia. However, there are no significant differences found between cognitive-behavioural therapy, supportive counselling and routine care in the case of relapse rate. Similarly, the researchers have not found any significant outcomes in the case of negative symptoms while administering cognitive-behavioural therapy or supportive counselling. In a long-term cognitive-behavioural therapeutic intervention, Wiersma et al (2001) argued about the implementation of the cognitive-behavioural therapy on developing coping skills training on persistent auditory hallucinations and social functioning. Studies conducted including 40 subjects with duration of four years using several assessment tools such as the Auditory Hallucinations Rating Scale (Haddock, 1994) and the Scale of Positive and Negative Syndrome (Kay et al, 1987) had been found robust effects on hallucinatory complications. However, the study provided numerous limitations as there was neither control group employed nor the assessors were independent. Moreover, the assessment of frequency and subjective burden of voices had been derived in retrospect including a lack of assessing social functioning or psychopathology regarding schizophrenia. Review of the studies suggest that 18% of the patients came out from the complications of hallucinations whereas 60% of the patients maintained improvement regarding the anxiety, loss of control and impaired thinking pattern, additionally 67% of the patients showed an overall improvement in daily functioning. As suggested by Kuipers et al (1997, 1998) a more comprehensive schema-focused approach involved reflection of the client's own interpretation of their problems by focusing attention to the development of onset of delusional ideas and hallucinations and its prevalence over time. The study aimed extensively at the development of coping strategies, problem-solving skills and prevention of relapse in relation to the declining of frequency and severity of psychotic symptoms in association with depression, anxiety, frustration, learned helplessness with an improvement of social functioning, enhancement of self-control of relapse and alternation of dysfunctional schemata. The study conducted by Kingdon and Turkington et al (2000) aimed at providing cognitive-behavioural therapy to reduce distress and disability stemmed from coexisting depression. The researchers concluded that both cognitive-behavioural therapies along with supportive interventions led to clinically significant progress in positive and negative symptoms as the outcomes of the treatment provided. Studies suggested that the combination of two treatment approaches like psychotherapeutic interventions along with antipsychotic medication provide more success compared to the single-line approach executed by antipsychotic medication only resulting in more relapse rate for the later (Left and Wing, 1971). During 1970s and 1980s increasing interests in finding the potential benefit associated with psychosocial intervention suggesting complications in relation to the implementation of single-line treatment of antipsychotic medications focused on four aspects in particular - (1) unpleasant side-effects, (2) persistence of negative symptoms, (3) limitations in social recovery and / or social bankruptcy and (4) deinstitutionalization. It had been further suggested the significance of family involvement during recovery as well as family's emotional or attitudinal viewpoint to the recovery of the patient in question in association with the progress in the concept of 'expressed emotion' (Linszen et al, 1998). The significance of stress-vulnerability model is reflected through current approaches to the clinical practices and research of psychosocial interventions. Hence the aim of psychosocial intervention is to lessen the effect of environmental stressors on organically vulnerable individuals while endorsing their social involvement and functioning within the community (Falloon et al, 1996). Neuroleptic pharmacotherapy is used to intervene on the primary symptoms of psychosis such as hallucinations, delusions and thought disorders, on the other hand, psychosocial therapeutics are equally important as they serve to educate, train and rehabilitate the patient to assist in fully functional recovery by means of regaining the capacity for psychological well-being, social and occupational involvement and enhanced quality of life in general. Interventions regarding Acute Psychosis However, there is not a plenty of research conducted in the area of post-acute, drug-refractory schizophrenia, but still there are studies suggesting that psychotherapeutic interventions may contribute to the recovery from acute psychosis (Grech, 2002). Studies conducted by Drury et al (1996a, 1996b, 2000) suggest the beneficial effect associated with administering cognitive-behavioural therapy in case of acute psychosis by asserting that 35% of the patients experienced long-term outcome of clinical significance (Birchwood et al, 1998; Garety & Jolley, 2000; Drake et al, 2000; Lenior et al, 2001). The therapeutic interventions were targeted to provide the alteration of delusional beliefs and related distress, improvements in negative symptoms and prevention of relapse. Findings showed that in intervention group 95% of the patients' modification in positive symptoms was of clinical significance in compared to the 44% of the patients' in control group. Both of the group showed an improvement in negative symptoms as well. A decline in the delusional conviction had been identified but no significant decline in the preoccupation in the delusional beliefs had been identified. Moreover, the definition of recovery from the acute phase of disorder corresponding to the 25% - 50% decline in the recovery time had been achieved (Drury et al, 1996b). Issues involved in working with psychotic patients and their problems Several studies suggest that there is a significant improvement observed among the patients suffering from schizophrenia if intervened with psychosocial rehabilitation programmes by means of achieving an evident improvement in the quality of life compared to the individuals received only standard care (Whitty, Lydon, Turner & O'Callaghan, 2006) as illustrated in figure 1. The psychosocial rehabilitation programmes facilitate the individuals suffering from psychotic symptoms provide necessary skills for learning and social integration resulting in an improved quality in life style and social functioning as a whole (Bachrach, 1992). However, there are number of issues raised in concern of conducting research in this area of study in essence of ethical, moral, legal and professional terms. With the introduction of atypical antipsychotic medication it has been clearly illustrated that there is an increase in the annual drug expenditure in a significant fashion (Kleinke, 2000), however, a significant strain has been put on the annual medical budget due to an escalation of in the medical expenses (Mehl & Santell, 2000), which results in an decline in the services associated with rehabilitation services as these are directed towards the payment for these medications (Baker, 2001). Moreover, the limitations for conducting psychotherapeutic control group in accordance with psychosocial intervention research may involve complicated ethical issues in terms of consent, confidentiality, boundary violations and risk-benefit issues (Saks et al, 2002). Studies suggest that there is a high satisfaction rate associated with the implementation of cognitive-behavioural therapy along with psychosocial intervention on the patients in general (Kuipers et al, 1997; Kemp et al, 1996, 1998). However, the efficacy of these interventions is largely untested due to inadequate knowledge and insufficient expertise involved during clinical trial (Cormac et al, 2002). Conclusion Several studies are in concordance with the growing evidence of effectiveness in implementing psychotherapy especially benefits associated with cognitive interventions over the non-specific supportive counselling and routine care in association with conventional neuroleptic pharmacotherapy. 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The Influence Of Psychosocial Rehabilitation On Patients With A First Episode Of Psychosis. International Journal of Psychosocial Rehabilitation. 10 (2) 17-27. Read More