Psychosocial Interventions for Psychosis

Gemma Stacey

Aims

To gain an overview of the stress vulnerability model

To identify interventions adopted within this model: Coping skills enhancement Relapse prevention

Apply the model to practice based scenarios.

Consider how the model may inform your approach to working with people with psychosis

What do you believe causes psychosis?

Stress

It may be said that all life events cause some degree of stress due to the adaptation involved.

The Stress Vulnerability Model maintains people who eventually suffer psychosis already had a

pre-disposition to the effects of stress.

What do we mean by stress?

Is it a physiological or psychological reaction?

Are there different types of stress? Does it effect every person in the same

way? What happens with short term stress? What happens with long term stress?

Stress and Stress ResponseActual Demand

eg work, child care, life events

Actual Capabilityeg health, resources, coping strategies

Perceived Capability Perceived Demand

Appraisal(How well we think we are doing)

Imbalance = Stress

Physiological Response

Psychological Response

Behavioural Response

Lazarus & Folkman (1984)

What do we mean by vulnerability?

When you think about people you have worked with, what factors do you think make them vulnerable to stress?

Stress Vulnerability Model

Vulnerability Factors pre-dispose individuals to develop problems e.g psychosis

Problems are triggered by stress

If vulnerability is high, low levels of environmental stress may trigger distress

Use and effectiveness of coping strategies goes some way to explain why some have problems and others don’t

A Stress &Vulnerability Perspective Assumes The experience of psychosis is

understandable.

Problems associated with the effects of stigma, social exclusion and poverty are of equal importance.

We take a collaborative approach to assessing, planning, formulating and delivering care.

A Stress &Vulnerability perspective assumes Each person is an expert in their own care.

Psychosis is on a continuum with other human experiences.

Psychosis can be an enriching, as well as a frightening/confusing experience.

The person over time, can make a recovery, in terms of what that actually means to them

Stress Vulnerability Model

Zubin, J. and Spring, B. (1977) Vulnerability. A New View on Schizophrenia. Journal of Abnormal Psychology 86, 103-126. APA. Reprinted with permission

The bucket

Formulation

Personal vulnerabilities

Environment stressors

Personal protectors

Environmental protectors

Family History

Disruptions in early years

Coping strategies

Self management

External factors that cause the person increased stress.

External sources of support.

Coping

Defined as: The active self generation of cognitive and behavioural procedures

intended either to impact upon situation directly or to minimise the resultant distress. (Nuechterline and Dawson 1984)

Functions of coping:

- To alter the source of stress

- To regulate the emotional response

(Lazarus et al 1985)

Coping

As part of the appraisal process in a stressful situation we examine our coping resources

The development of these coping strategies is affected by a number of factors including….....

Coping

Personality Psychosocial development Locus of Control - Is it my fault? - Was it fate? Social Support - What relationships will help me

fulfil my needs for coping Implications for isolated groups such as people

with mental health problems and the elderly (Shaw 1999)

Aims of Working with Coping Strategies

To foster feelings of self control and to help the client manage their own experiences and problems

To reduce distress and/or disability

Coping Styles

Detachment - Being independent from the event, not taking anything personally, not seeing the situation as a threat, keeping things into proportion

Rational Coping - looking for a reasonable response, using past experience to work out how to resolve a situation, problem solving

Coping Styles

Emotional Coping- Emotions dominate, taking frustrations out on other people, feeling overpowered and helpless

Avoidance Coping - Ignoring or denying the problem, hoping it will go away, thinking about something else and talking about it as little as possible.

Classification of Coping Strategies Cognitive Strategies attention switching attention narrowing self-statement Think of something

different Read silently Look for explanations of

what's going on

Behavioural Strategies increased activity levels increased social activity decreased social activity Talk to someone about

the stressor

Classification of Coping Strategies Sensory Strategies

Relaxation exercises

Meditation

Relax in bath or shower

Hum or sing to self

What is relapse prevention?

Service users, carers and MH workers identify each individuals early warning sings of relapse (relapse signature)

Agree and record in advance the nature of

and timing of interventions if the signs return (relapse drill).

Benefits of Relapse Prevention

Collaborative process were service users are viewed as the experts of their experience.

Acknowledges personal strategies, skills and resources for self management.

Enables relapse to be predicted and interventions put in place to prevent or minimise negative impact on the individual.

Evidence based.

Stages of Relapse Prevention

Psycho-education Two way process where the service user and

practitioner work together to understand the individual nature of the persons experience.

Can involve the use of Stress Vulnerability Model to facilitate the process.

Stages of Relapse Prevention Identification of Early Warning Signs (prodromal

symptoms)

Highly diverse and vary from person to person.

General examples Anxiety Agitation Mistrust

Specific behavioural patterns (idiosyncratic) Eccentric clothing Flamboyant hair styles

Identifying Early Warning Signs Card sorting exercise

Client identifies early warning signs using cards Arranges into early, middle, late and constant

Review information from both exercises with close family/ friends to identify gaps that service user finds difficult to remember.

Limitations Tendency to overlook EWS which are individual to

that person. Formulated in the MH workers language

Identifying Early Warning Signs

Timeline A detailed account of the persons narrative of the events and

experiences leading up to previous relapse.

Also identifies factors that have an impact on the onset of relapse eg external and internal stressors.

What might be the limitations/challenges of this approach?

Monitoring

Direct- Presence or absence of EWS are scored by the service user.

Indirect- Changes in circumstances, stressful life events or reoccurrence of circumstances which led to previous relapse.

Stages of Relapse Prevention

The development of a relapse drill

A 3 stage action plan developed collaboratively and focuses on client strengths, family and service resources

at each stage the relapse drill should consider 3 areas for intervention Pathway to support. Service interventions. Personal coping strategies.

Relapse Signature

1. Feel worried about what Cathy next door thinks of me

2. Cant get to sleep at night

3. Loose my temper with John

4. Stay inside and don’t see Cathy

5. Here my mums voice talking about how nobody likes me

6. Cut my arms to punish myself for being a horrid person.

Relapse Drill

1. Talk to John and Gemma about how I am feeling

2. Challenge my thoughts about Cathy

3. Watch TV to talk my mind of my worries

4. Have a bath and listen to music

5. Talk to Gemma about medication options.

6. Consider going into hospital

Emergency Contact Details

Challenges to Relapse Prevention

The service user may not agree with the perceptions of carers or MH workers.

Some people cope with MH problem by “sealing over” and are therefore unlikely to want to consider past experiences and the possibility of future relapse.

Many people experience difficulty with structuring their

own reality (lack of insight) leading up to relapse.

Feelings of guilt in the service user if relapse still occurs.

Using the Stress Vulnerability Model to Assess and Plan Care Use the case study to complete the SVM

formulation.

Is their any other information you would need to assess this person.

How would you use this information to plan care.

References Lazarus, R.S. & Folkman, S. (1984). Stress, Appraisal

and coping. New York: Springer. Nuechterlein, K. and Dawson, M. E. (1984) A Heuristic

Vulnerability-Stress model of Schizophrenia Schizophrenia Bulletin, 10,300-12

Shaw, C. (1999) A framework from the study of coping illness behaviour and outcomes. Journal of Advanced Nursing 295 1246-1255

Zubin, J. and Spring, B. (1977) Vulnerability. A New View on Schizophrenia. Journal of Abnormal Psychology 86, 103-126.