Thursday 7 th November 2019 Better outcomes for schizophrenia: a patient-centred approach
Tonight’s panel Russell Dr Richard Lakeman Facilitator: Dr Melissa Connell Dr Cathy Andronis Lived Experience Mental Health Nurse Julianne Whyte Psychologist General Practitioner Advocate Mental Health Social Worker
Learning outcomes Through an exploration of schizophrenia the webinar will provide participants with the opportunity to: • Describe the common symptoms and causes associated with schizophrenia • Identify the challenges, merits and opportunities in evidence-based approaches deemed most effective in treating and supporting people experiencing schizophrenia • Facilitate clinical and personal recovery in a primary care setting for people who may experience psychosis or be diagnosed with schizophrenia.
Believe Surround yourself with people that believe in the same thing: • Be it your doctor or health professionals or even the church Believe in the medication: • Take your medication religiously and seek support if you need. Russell
Acceptance • Accept the illness and love yourself warts and all • Having acceptance that you have a medical condition means you have a greater insight into what most others don’t • The weakness is also a strength. You can gain valuable insight from others whom are willing to help you. Think of it as personal coaching or mentoring. Russell
Ups and downs Even the biggest of ships will self-right if tipped: • Always know if things do go pear shaped, life cycles will always fix things naturally and without trying too hard for perfectionism Sometimes just thinking of a favourite food helps take the edge off difficult times when you need to feel grounded within yourself Plan where you will sit at Christmas or family gatherings: • Often these times are the hardest so fit yourself in by contriving a comfortable place for yourself. Russell
Diagnosis and aetiology of schizophrenia DSM5 Two or more of the following for at least a one-month, and at least one of them must be 1, 2, or 3: • Delusions • Hallucinations • Disorganised speech • Grossly disorganised or catatonic behaviour • Negative symptoms, e.g., reduced emotional expression • Impairment in one of the major areas of functioning for a significant period of time since the onset of the disturbance: work, interpersonal relations, or self-care • Overall symptoms / reduced functioning at least 6 months. Schizoaffective disorder and bipolar or depressive disorder with psychotic features have been ruled out: • Causes • Genetics • Environment • Brain chemistry • Substance use Dr Cathy Andronis
Common symptoms and challenges associated with schizophrenia • Diagnosis is often unclear and uncertain – it is common to receive multiple or provisional diagnoses over time, especially for chronic presentations • Diagnostic uncertainty is distressing for patients and stigmatising • GPs are sometimes placed in a “double bind” - they must label patients in order to prescribe some medications or treatments or prepare plans (PBS, Medicare) but they need to remain sensitive to the patient’s needs and concerns • Cynthia is a fairly typical patient but everyone has their unique story and GPs are expert at individualised patient care – this is optimised by continuation of care and developing a trusting relationship between doctor and patient. Patients who have a regular, reliable GP have best outcomes • Multiple challenges, merits and opportunities in evidence-based approaches deemed most effective in treating and supporting people experiencing schizophrenia. Dr Cathy Andronis
Good engagement with usual GP on a regular basis, important for: • Managing negative symptoms especially poor motivation, social withdrawal / isolation • Also issues of anxiety, ambivalence, stigma • Active follow up and engagement is a whole of practice approach (safety netting) • Multidisciplinary care and GP awareness of local services is vital. Regular communication between the GP and other providers improves outcomes and results in better support of the providers as well as the patient • Facilitating clinical and personal recovery in a primary care setting for people who may experience psychosis or be diagnosed with schizophrenia • Treat the patient not the disease. Dr Cathy Andronis
The holistic approach • GPs often understand the patient’s context and may know their family or other supports. This is helpful in avoiding isolation but also for appreciating triggers or assessing risks • Supportive long term care and counselling with a familiar GP is sometimes the only trusted provider for some patients and at some stages of their life • Patients with a schizophrenia diagnosis do benefit enormously from regular contact and counselling with FPS providers and are usually capable of engaging with all FPS modalities with a trusted therapist • Building engagement slowly and patiently, making allowances for negative symptoms and avoiding judgements is critical. Dr Cathy Andronis
The role of the psychologist on the treating team The value of psychological approaches to psychosis: • develop self understanding and effective coping strategies • reduce reliance on medications • avoid hospital admissions • support recovery Referral and access to psychologists: • Better Access • NDIS • private health insurance • mental health services Dr Melissa Connell
History, assessment and formulation History: • developmental history • time-line (what’s happened and how it has affected Cynthia ) • stress-vulnerability model • Assessment tools (e.g. PSYRATS, Maastricht Interview, BPRS) Collaborative formulation: • working together • developing trust • understanding how Cynthia makes sense of her experience • coming up with a working hypothesis Treatment plan Dr Melissa Connell
Immediate goals of therapy • Reduce anxiety and distress • Build coping skills • Explore possible unprocessed grief associated with loss of father • Improve mood • Increase activities (e.g. painting, seeing friends, going out) • Recovery orientation Dr Melissa Connell
Working with voices and delusions Psychological approaches: • ACT for psychosis, Relating Therapy, CFT for psychosis, CBT for psychosis Aims: Voices • Appraisal of voices, understanding beliefs, changing the relationship with voices Delusions • Distress reduction, engagement in meaningful activity, alternative explanations Dr Melissa Connell
Long term goals • Recovery focus – improving self-esteem, connecting with others, finding meaning, hopefulness, self-determination, developing more adaptive resources for coping, community supports • Understanding personal stress-vulnerability factors, relapse prevention • Ongoing support for managing anxiety and voices • Groups – e.g. Hearing Voices • Explore unresolved trauma (assess traumatic memories, potential benefits of trauma-focused treatments such as Eye Movement Desensitization and Reprocessing ( EMDR) Dr Melissa Connell
Orientation phase of relationship / alliance building • Getting to know each other and building a shared understanding • Attempting to understand the world as Cynthia experiences it: curiosity, humility, respect, openness • Empathic listening – particularly for the as yet untold story • Assessment – ? Maastricht Interview for Voice Hearers • Normalising extra-ordinary experiences such as hearing voices, jumping to conclusions etc • Explore and promote positive mental health – positive emotion, engagement, relationships, meaning, and accomplishment + physical activity, nutrition, sleep • Mobilise and / or extend supportive networks e.g. Hearing Voices Network. Dr Richard Lakeman
Identification / working phase • Cynthia begins to identify the nurse as a helping person • Detailed developmental and trauma history • Strengthening and mobilising resources • Coaching around dealing with paranoia and intrusive thoughts e.g. • Having a thought does not make it a fact (I thought…. But I really know that….) • Having a strong feeling doesn’t mean that something will happen (I feel…. But I know that….). Dr Richard Lakeman
Identification / working phase • Assist with coping with voices: • Intrusiveness / beliefs about voices (omnificence and omnipotence) • Rationalising medication and clarifying the expected effects of medication • Arriving at a working problem formulation (a shared way of making sense of the problem) • Goal setting and negotiating a way forward. Source: https://testandcalc.com/voices/ Dr Richard Lakeman
Exploitation / working / ending • Cynthia begins to exploit the helping relationship to clarify needs and have these met • Therapy as negotiated and as suggested by the formulation • Advanced empathy • Recovery planning / relapse prevention – Who does what? • Referrals as needed. Lakeman R. Adapting psychotherapy to psychosis. Australian e-Journal for the Advancement of Mental Health. 2006;5(1):22-33. Dr Richard Lakeman
Q&A Russell Dr Richard Lakeman Facilitator: Dr Melissa Connell Dr Cathy Andronis Lived Experience Mental Health Nurse Julianne Whyte Psychologist General Practitioner Advocate Mental Health Social Worker
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