Recovery
A Focus on Recovery
The first-onset of psychosis can be a very traumatic experience. It has the capacity to profoundly change a person’s usual way of construing themselves, their environment and their future. Overall, the major aims of psychological interventions in early psychosis are to assist the person to understand their condition and to help them regain a sense of mastery over their life, despite the sense of trauma. It is particularly important to protect and enhance the person’s self-esteem, which has often been severely threatened or damaged by the onset of the disorder. Interventions need to instil hope, foster a positive yet realistic sense of self, and encourage and build on existing strengths.
Early Issues
During the initial treatment period, the young person is probably still unwell and will generally feel alone, misunderstood, confused and fearful about what is happening. They may feel powerless and feel that all control has been taken from them. As a consequence, they may experience anger and frustration at being forced to do something they don’t want to do. In assisting people at this time, it is important to make an effort to fully understand how the person sees the situation and try to convey this understanding to them, trying to find some common ground with them about their difficulties, despite their psychosis. Where it becomes necessary to take control and take more assertive action, the emphasis is on conveying a sense of understanding their fear, giving clear information about what to expect and negotiating around the choices that are still possible.
Early recovery phase
With the use of antipsychotic medication, most people will experience a resolution of their positive symptoms (delusions, hallucinations and thought disorder) over several weeks. Some people will take longer to respond to treatment.
At this stage it is helpful to talk about recovery as a phase – a period of recuperation after a difficult illness – that takes time, emphasising that improvement will continue to occur over the coming months.
It may help to describe other peoples’ experiences of recovery and the problems that can occur, while encouraging discussion of the young person’s own experience. The overall emphasis is to try to reduce fear and distress evoked by the psychosis by giving clear information about psychosis, assisting the person to begin to make some sense of why it happened and working towards encouraging the patient to separate self from illness.
It is also useful to explain psychosis in terms of the stress vulnerability model, highlighting the interaction between biological predisposition and environmental influences, in particular the role of stress in lowering the threshold to psychosis. This can allow you to emphasise the episodic nature of psychosis and to highlight the possibility for the patient to have some control over managing their illness.
Another essential task is to discuss the person’s medication, making sure they understand what each of their medications are for and to proactively dispel common myths about medication. If you dont know the specifics of the medication, tell the young person this, but also work with them to find out.
As their symptoms begin to subside, people can start to experience profound changes in the way they view themselves. Some will have a sense of extreme loss and grief due to a feeling that everything has changed. Others may make attempts to deny or minimise what has happened, or work hard to find alternative explanations for the episode.
It is important to respect the young person’s need to deny some aspects of their experience or unwillingness to talk about certain issues. In addition, a number of people may have experienced their psychotic symptoms, their entry into treatment, or some of the interventions used in the active phase as frightening or even traumatic, and may continue to ruminate on these memories.
As recovery progresses it is essential to be on the look out for any possible secondary morbidity, in particular post-psychotic depression and anxiety, and tackle any new problems in a proactive way.
Late Recovery
The young person at this stage generally feels much better, though may be not quite the same as they used to be. They may lack confidence, particularly in social situations and other activities requiring their usual level of independence. They may also have some continuing mild cognitive difficulties, particularly with concentration and their level of motivation may still be reduced.
They are usually very aware of stigma and extremely fearful of relapse. They may now wish to really distance themselves from what has happened and express the desire to cease medication.
The emphasis is on helping the person gradually return to their previous activities and reinforcing their sense of identity. It can be helpful to focus on reducing the person’s fear of relapse by looking at the early signs of becoming unwell for them and emphasise the idea of early intervention, should they ever re-experience symptoms.
Indeed, it may be useful to create an individual warning signs list, along with a preferred management plan. The current and future use of medications can then be negotiated within this ‘early signs monitoring’ framework.
For many young people it is also necessary to give information on the ways some illicit drugs and alcohol may interact with their illness and medications. This is part of the broad context of helping the person to identify ways to stay well, including the avoidance of potential triggers for relapse.
Persistent Symptoms
While most young people will make a full recovery from their first psychotic episode, a significant minority will develop persistent symptoms. These young people will need a comprehensive multidisciplinary approach to their management, which is best arranged through the specialist mental health services.
Continuing Care
The main aim after remission of positive symptoms is to promote wellness and prevent relapse. Optimising a return to a normal, social, and educational level of functioning is a priority; there is emerging evidence that the sooner in the recovery process this occurs, the better. Continuing care is therefore far from a passive process and requires a structure and purpose for each encounter. This is covered more extensively on the Psycho-social page.
The following issues need to be considered at each appointment:
- Review of general health and well-being
- Assess mental state, including assessment for secondary depression and anxiety (risk assessment if required)
- Review medication (adherence, side-effects, changes required)
- Attend to any practical problems (eg finances, housing)
- Provide supportive counselling or specific counselling (eg stress management through behavioural measures or structured problem solving, counselling regarding drug use)
- Assistance with a return to school or employment and a normal social life
- Plan next session and any tasks required in the interim
It is also important the young person and clincian agree to an action plan in case of non-attendance (which may signal the onset of relapse) and a relapse action plan. Both of these plans may well require input from the person’s family.
Elements of the relapse plan should include:
- Identifiying triggers to relapse
- Possible early and late warning signs of relapse (these are often, though not always, similar symptoms to those in the previous psychotic episode)
- A medication plan on what to do, should warning signs be evident