Beyond Medication: Therapeutic Engagement and the Recovery from Psychosis

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Both the editors and contributors challenge the established medical model by placing the therapeutic relationship at the centre of the treatment process, thus supplanting medication as the single most important element in recovery. Divided into three parts, topics of focus include: Strengthening the patient The mechanism of therapeutic change Sustaining the therapeutic approach.

This book will be essential reading for all mental health professionals working with psychosis including psychoanalysts, psychiatrists, psychologists and social workers. Passar bra ihop. Unbearable Affect David Garfield. Recensioner i media. Bloggat om Beyond Medication.

Serious disabilities in these domains qualify for scores in the 40's, e. Function scores below 40 represent major disability in several areas, whereas scores in the 30's reflect inability to function in almost all areas, including disability of self-care and the need to be taken care of by others.

Beyond Medication: Therapeutic Engagement and the Recovery from Psychosis (Electronic book text)

All GAF scores were set in ordinary clinical care; however, they were decided upon as consensus ratings between at least two trained psychiatrists, a method documented to increase reliability For the purpose of this study, an external, independent psychiatrist extracted the GAF scores from the patients' medical journals. A baseline score was obtained from the first evaluation documented in the patient journals after start of treatment in the study period.

A second score was obtained at follow-up, defined as end of treatment or end of study period September 1st , which ever occured first. In both treatment groups, psychopharmacological treatments were managed by different psychiatrists in charge. The prescribers did not use a shared decision making approach. All medications belonging to the same subgroup were added to derive at a summated dose for that subgroup. We also counted the total number of all psychoactive medications used.

The psychiatrist who scored the use of medications also counted the number of hospital inpatient admissions, the total number of days spent in hospital, and treatment duration for outpatient treatments. These data were collected from the summary of each separate admission in the medical journals. There were no evaluations involved in these extractions and registrations.

All data extractions were controlled by a collaborator. Hospital admissions and days spent in hospital were calculated for two time periods. First, a baseline measure that included all life time hospital stays prior to enrolment in outpatient treatment at POC. Second, a follow up measure for the time period after end of outpatient treatment at POC in the study period.

Treatment duration was defined as months in outpatient treatments at POC during the study period. Information about the duration of outpatient treatment, number of days in hospital inpatient treatment and number of hospital admissions were extracted from the patients' journals.

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In DT, on average, one therapeutic session was provided each week for each patient. Differences between patients in the two treatment conditions at baseline were tested with independent sample t -tests for GAF and age, Chi square test for gender, and Mann-Whitney U -tests for medications. Mann-Whitney U -tests were used to test differences in the number of hospitalizations and number of days in hospital before baseline and after treatment within each study group, and differences between the two study groups were analyzed with multiple regression analyses.

To investigate impacts of treatment group upon GAF and medications we focused both on scores at follow up and on changes from baseline to follow up. For GAF, we calculated effect size using Cohen's d. Next, we performed more detailed analyzes with control for covariates.

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For GAF, we used general linear modeling, with treatment group as fixed factor and, as covariates, diagnostic group schizophrenia, other psychoses , gender, age, number of days spent in hospital before treatment, and number of hospital stays before treatment. In these models we included as a covariate the interaction between treatment groups and diagnostic group, in order to investigate if an eventual superior effect of DT or ST was limited to just one of the two diagnostic groups.

For medications, we used linear regression, with treatment condition, diagnostic group, gender, age, and the two noted hospitalization variables as predictors. At baseline, there were no significant differences between the DT and ST groups in age or gender distribution Table 1 , or in GAF scores or the use of any type of medication left columns in Tables 2 , 3. Table 2. Table 3. Changes in medications over the treatment course in Dialogue therapy and Standard treatment.

At baseline, patients with other psychoses were significantly older than patients with schizophrenia [mean age Compared to patients with schizophrenia, patients with other psychosis also had higher baseline scores on GAF-S, [mean The effect size Cohen's d favoring DT was 1. Figure 1. GAF scores at baseline and follow up for patients in Dialogue therapy and Standard treatment. At follow up there was no significant difference in GAF scores between the schizophrenia group and other psychoses.

The interaction between treatment groups and diagnostic category schizophrenia, other psychosis was not significant for any of the two GAF sub-dimensions, indicating a superior effect of DT over ST independent of diagnosis. No effects were seen for the covariates. Noteworthy, the interaction between treatment group and diagnostic category was not significant in any of the models, suggesting comparable effects of DT for patients with schizophrenia and for patients with other psychoses.

See Table 2 for details about GAF scores at baseline and follow up and Figure 2 for changes in GAF scores from baseline to follow up, paneled by diagnostic group. Figure 2. Changes in GAF scores from baseline to follow up for two diagnostic subgroups in Dialogue therapy and Standard treatment. No interact effects were seen between treatment groups and diagnostic categories, indicating a larger improvement in GAF scores in DT as compared to ST both for patients with a schizophrenia diagnosis and patients with other diagnoses for illustration, see Figure 2.

No other covariates were significant predictors in multiple regression analyses. As can be seen in Table 3 , medications in general increased across the treatment course in the ST group but decreased in the DT group. Figure 3. Use of low-dose neuroleptics at baseline and follow up in the two treatment groups. Figure 4. Use of high-dose neuroleptics at baseline and follow up in the two treatment groups. The regression analysis for changes from baseline to follow-up in the use of medication was significant for low-dose neuroleptics, antidepressants, and other medications.

There was no significant difference between the treatment groups in number of patients without medication before start of treatment. However, when one extreme outlier in the DT group was removed from the analyses, no effect remained for treatment group upon hospitalization days.


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We have previously reported larger improvements in symptoms and functioning after DT compared to ST in patients with schizophrenia diagnoses In the current, extended exploratory analysis we report that in both patients with schizophrenia and in patients with diagnoses for other psychoses, larger improvements in symptoms and functioning were seen after DT than ST. Concomitant with these differences were larger reductions in the use of psychopharmaca in patients who completed DT as compared to ST, including low dose neuroleptics, antidepressants, and the number of psychoactive drugs.

Across treatment, much larger improvements in GAF scores in favor of DT were seen for both schizophrenia patients and for patients with other psychotic diagnoses. Considering the two diagnostic domains together, in the DT group, GAF symptom scores at follow up were moderate to high, representing the remaining of only mild stress symptoms and temporary and understandable reactions to psychosocial stress. Most notably, scores at the observed level indicated the general absence of psychotic symptoms and any other marked emotional and cognitive psychiatric symptoms.

In contrast, in the ST group, GAF symptom scores were still low at follow up, in line with the remaining of serious symptoms in need of treatment. Regarding GAF function scores at follow up, in the DT group, they represented good functioning and only slight, if any decrease in the domains of social life, occupation, and education, with no need of assistance from the mental health system.

The larger improvements in GAF scores in DT could not be explained with increased medical treatments since medications rather were markedly reduced in DT as compared to ST across the treatment course. Nor could it be explained with longer duration of outpatient treatment, since DT on average had shorter duration than ST. The strong improvements in symptoms and functioning in DT compared to ST, combined with the reduction in use of medication, strengthen the assumption that the effective component included psychological changes based on a psychotherapeutic process.

DT has an explicit focus on recovery from psychosis and aims both at symptom reduction through a therapeutic process oriented toward insight and self-regulation, and at helping the patient back to adequate functioning at home and in the society in general. Studies of treatment effects indicate that people diagnosed with schizophrenia may benefit from acquiring insight into their internal states and the external circumstances of their illness.

This may help them to see causal connections and develop histories about themselves that they better can live with 16 , 33 , consistent with the goal of DT. We suggest that psychotherapy for schizophrenia and other psychosis should emphasize the opportunity to restore health and enable patients to develop adequate self-narratives 24 , It may also seek to reduce stigma and transform the language of psychopathology to a more restorative one of hope and empowerment 11 , 34 — People who experience psychosis describe stigma and attitudes from health professionals and the community related to having a schizophrenia diagnosis, as more life-limiting than the illness itself 37 , There is an ethical case to be made for broadening our scientific understanding of schizophrenia and other psychoses, allowing for emotions and the patient's experience of a psychosis to be more fully included in psychotherapy 3 , 17 , 34 , 36 , 38 , Since therapist factors may have a strong impact on outcome, a limitation is that DT involved a single therapist only; the apparent benefits of DT could alternatively reflect the particular skills and dedication of this therapist.

At the same time, because only one therapist practiced DT the founder of the model , adherence and fidelity checks have been less relevant to implement. On the other side, this has ensured a stable, comparable practice of DT for all its patients. However, the survey must be considered preliminary and exploratory, and controlled prospective studies that include more therapists providing DT are needed. Strengths include that all patients who received DT and fulfilled criteria for psychosis, were included in the study, and that the ST group was matched on several criteria to the DT group.

However, the likely varied approaches in ST makes it difficult to know exactly what DT was compared to. A further limitation is that although GAF scores were set in consensus by at least two trained professionals, this was done in ordinary clinical care, with no independent scores set by researchers.

Hearing Voices & ‘Psychosis’ – Jacqui Dillon

Other weaknesses are that patients were not allocated to treatment groups using conventional randomization methods; the small size of the sample investigated; the limited range of outcome measures; and the dependence of the outcome measures on information in the clinical notes. Moreover, even if strengths include that all patients who received DT and fulfilled criteria for psychosis were included in this study, the limited range of outcome measures does not allow deepening the complexity of the sample, which includes the entire psychosis spectrum.

We had no measure of the proportion of patients in ST who received psychoeducation and medication vs. Thus, suboptimal aspects of ST for some patients may have contributed to this group's worse outcome compared to DT. In this preliminary and exploratory study, compared to standard treatment, the psychotherapeutic approach Dialogue therapy was associated with improved functioning and reduced levels of general symptoms at follow up in both patients with schizophrenia and patients with other psychosis.

The differences were seen in spite of reduced use of medication and shorter duration of therapy in DT. These promising findings for DT warrant subsequent controlled studies that include larger patient groups and more therapists in order to conclude about effects. AH, TH, and RF have made substantial contributions to conception, design, analysis, interpretation of data, and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

AH, TH, EJ, and RF have been involved in interpreting the data and drafting the manuscript or revising it critically for important intellectual content. All authors read and approved the final version of the manuscript. AH has developed the new psychotherapeutic approach and published a book about the method. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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