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Psychological Interventions In Early Psychosis
Psychological
Interventions in Early
Psychosis
A TREATMENT HANDBOOK
Edited by
JOHN F.M. GLEESON AND PATRICK D. MCGORRY
The University of Melbourne, Australia
Copyright C 2004 John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester,
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Library of Congress Cataloging-in-Publication Data
Psychological interventions in early psychosis : a treatment handbook /
edited by John F.M. Gleeson and Patrick D. McGorry
p. cm.
Includes bibliographical references and index.
ISBN 0-470-84434-5 (cloth)—ISBN 0-470-84436-1 (paper : alk. paper)
1. Psychoses—Treatment. 2. Cognitive therapy. I. McGorry, Patrick D.
II. Gleeson, John.
RC512 .P7365 2003
616.89
14—dc22 2003022091
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
ISBN 0-470-84434-5 (hbk)
ISBN 0-470-84436-1 (pbk)
Typeset in 10/12pt Times and Sans Serif by TechBooks Electronic Services, New Delhi, India
Printed and bound in Great Britain by TJ International Ltd, Padstow, Cornwall
This book is printed on acid-free paper responsibly manufactured from sustainable forestry
in which at least two trees are planted for each one used for paper production.
Contents
About the Editors vii
Contributors ix
Foreword xiii
Preface xv
1 An Overview of the Background and Scope for Psychological Interventions
in Early Psychosis 1
Patrick D. McGorry
2 Changing PACE: Psychological Interventions in the Prepsychotic Phase 23
Lisa J. Phillips and Shona M. Francey
3 Cognitive-Behavioural Therapy for Acute and Recent-Onset Psychosis 41
Ron Siddle and Gillian Haddock
4 Psychological Intervention in Recovery from Early Psychosis:
Cognitively Oriented Psychotherapy 63
Lisa Henry
5 The Dynamics of Acute Psychosis and the Role of Dynamic Psychotherapy 81
Johan Cullberg and Jan-Olav Johannessen
6 Working with Families in the Early Stages of Psychosis 99
Jean Addington and Peter Burnett
7 A Group Psychotherapeutic Intervention During Recovery From
First-Episode Psychosis 117
Ashok K. Malla, Terry S. McLean and Ross M.G. Norman
8 Cannabis and Psychosis: A Psychological Intervention 137
Kathryn Elkins, Mark Hinton and Jane Edwards
9 The First Psychotic Relapse: Understanding the Risks, and the
Opportunities for Prevention 157
John F.M. Gleeson
10 Suicide Prevention in Early Psychosis 175
Paddy Power
11 Psychological Treatment of Persistent Positive Symptoms in Young People
with First-Episode Psychosis 191
Jane Edwards, Darryl Wade, Tanya Herrmann-Doig and Donna Gee
vi CONTENTS
12 Cognitive Therapy and Emotional Dysfunction in Early Psychosis 209
Max Birchwood, Zaffer Iqbal, Chris Jackson and Kate Hardy
13 Principles and Strategies for Developing Psychosocial Treatments
for Negative Symptoms in Early Course Psychosis 229
Paul R. Falzer, David A. Stayner and Larry Davidson
14 Making Sense of Psychotic Experience and Working Towards Recovery 245
Rufus May
15 Psychological Therapies: Implementation in Early Intervention Services 261
Grainne Fadden, Max Birchwood, Chris Jackson and Karen Barton ´
Index 281
About the Editors
John F.M. Gleeson is currently Associate Professor in the Department of Psychology,
The University of Melbourne and the Northwestern Mental Health Program (a program
of Melbourne Health). His major research interests include secondary prevention in psychotic disorders, and he is currently the Chief Investigator of a randomized trial at
EPPIC, examining the effectiveness of a multi-modal relapse prevention intervention.
He was previously Acting Director of Clinical Programs and Senior Psychologist at
ORYGEN Youth Health, which incorporates the EPPIC Program. He has previously held a
range of senior clinical and teaching roles at EPPIC since 1994. In 1998 he developed
a Graduate Diploma in Young People’s Mental Health, and has lectured extensively,
nationally and internationally, on psychosocial treatments in first-episode psychosis.
Patrick D. McGorry is currently Professor/Director of ORYGEN Youth Health, which
is linked to The University of Melbourne and the Northwestern Mental Health Program
in Melbourne, Australia. He has contributed significantly to research in the area of early
psychosis over the past 16 years. Over that time he has played an integral role in the
development of service structures and treatments specifically targeting the needs of young
people with emerging or first-episode psychosis. More recently there has been a broadening
of his focus to cover the full spectrum of mental disorders in young people. In the last
2 years he has published over 50 journal articles and chapters in many well-respected
international journals such as the American Journal of Psychiatry, Schizophrenia Research
and Archives of General Psychiatry. He is currently the President of the International Early
Psychosis Association and an Executive Board Member of the International Society for the
Psychological Treatments of the Schizophrenias and other Related Psychoses. He is also
a member of the Organizing Committee of the World Psychiatric Association Section on
Schizophrenia, the Advisory Board of UCLA Center for the Assessment and Prevention of
Prodromal States (CAPPS) and a member of the Editorial Board of Schizophrenia Research.
Contributors
Dr Jean Addington, Associate Professor, Department of Psychiatry, University of Toronto,
Center for Addiction and Mental Health, 250 College Street, Toronto, Ontario M5T 1R8,
Canada
Karen Barton, Assistant Psychologist, Birmingham Early Intervention Service,
Harry Watton House, 97 Church Lane, Aston, Birmingham B6 5UG, UK
Professor Max Birchwood, Director, Early Intervention Service and Director of Research
and Development, Northern Birmingham Mental Health Trust and School of Psychology
University of Birmingham, Harry Watton House, 97 Church Lane, Aston, Birmingham B6
5UG, UK
Dr Peter Burnett, Medical Director, ORYGEN Youth Health, Parkville Centre, Locked
Bag 10/35 Poplar Road, Parkville, Victoria 3052, Australia
Professor Johan Cullberg, Professor of Psychiatry, Stockholm Center of Public Health,
PO Box 17533, Stockholm, Sweden
Dr Larry Davidson, Associate Professor of Psychiatry and Director, Program for Recovery
and Community Health, Yale University School of Medicine and Institution for Social and
Policy Studies, Yale Program for Recovery and Community Health, Erector Square, Bldg
#6W, Suite #1C, 319 Peck Street, New Haven, CT 06513, USA
Jane Edwards, Deputy Clinical Director, ORYGEN Youth Health, Parkville Centre,
Locked Bag 10/35 Poplar Road, Parkville, Victoria 3052, Australia
Kathryn Elkins, ORYGEN Youth Health and Department of Psychiatry, The University
of Melbourne, Parkville Centre, Locked Bag 10/35 Poplar Road, Parkville, Victoria 3052,
Australia
Dr Gr´ainne Fadden, Consultant Clinical Psychologist, MERIDEN Programme, SBMHT,
Academic Unit, 71 Fentham Road, Erdington, Birmingham B23 6AL, UK
Dr Paul R. Falzer, Clinical Assistant Professor of Psychiatry, Program for Recovery and
Community Health, Yale University School of Medicine and Institution for Social and
Policy Studies, Yale Program for Recovery and Community Health, Erector Square, Bldg.
#6W, Suite #1C, 319 Peck Street, New Haven, CT 06513, USA
Dr Shona M. Francey, Coordinator/Psychologist, PACE Clinic, ORYGEN Youth Health
and Department of Psychiatry, The University of Melbourne, Parkville Centre, Locked Bag
10/35 Poplar Road, Parkville, Victoria 3052, Australia
x CONTRIBUTORS
Donna Gee, Research Therapist, ORYGEN Youth Health, Parkville Centre, Locked Bag
10/35 Poplar Road, Parkville, Victoria 3052, Australia
Dr John F.M. Gleeson, Associate Professor, Department of Psychology, The University
of Melbourne and the Northwestern Mental Health Program, Parkville Centre, Locked Bag
10/35 Poplar Road, Parkville, Victoria 3052, Australia
Dr Gillian Haddock, Reader in Clinical Psychology, University of Manchester, Tameside
General Hospital, Fountain Street, Ashton-u-Lyne OL6 9RW, UK
Kate Hardy, Assistant Psychologist, South West Yorkshire Mental Health NHS Trust,
Early Intervention Project, Ravensleigh Cottage, 28a Oxford Road, Dewsbury, UK
Lisa Henry, Research Fellow and Clinical Psychologist, ORYGEN Youth Health and
Department of Psychiatry, The University of Melbourne, Parkville Centre, Locked Bag
10/35 Poplar Road, Parkville, Victoria 3052, Australia
Tanya Herrmann-Doig, c/o Chris Mackey & Associates, Clinical Psychology Services,
28 Villamanta St, Geelong West, Victoria, Australia
Mark Hinton, Consultant Clinical Psychologist, Early Intervention Services, Camden and
Islington Mental Health and Social Care Trust, St Pancras Hospital, 4 St Pancras Way,
London NW1 0PE, UK
Dr Zaffer Iqbal, Senior Clinical Research Fellow, University of Birmingham and Leeds
Mental Health Teaching NHS Trust, CPPP Services, 17 Blenheim Terrace, Leeds LS2 9HN,
UK
Dr Chris Jackson, Early Intervention Service, 97 Church Lane, Aston, Birmingham
B6 5UG, UK
Professor Jan-Olav Johannessen, Chief Psychiatrist, Rogaland Psychiatric Hospital,
Postboks 1163, 4095 Stavanger, Norway
Professor Ashok K. Malla, Professor of Psychiatry, University of Western Ontario, PEPP–
London Health Sciences Centre, 375 South Street, London, Ontario
N6A 5G6, Canada
Dr Rufus May, Clinical Psychologist, Bradford Assertive Outreach Team, Bradford District
Community Trust, 48 Ash Grove, Bradford BD7, UK
Terry S. McLean, Clinical and Education Leader, PEPP–London Health Sciences Centre,
WMCH building, 392 South Street, London, Ontario N6A 4G5, Canada
Professor Patrick D. McGorry, Director, ORYGEN Youth Health (incorporating EPPIC),
Department of Psychiatry, The University of Melbourne, Parkville Centre, Locked Bag
10/35 Poplar Road, Parkville, Victoria 3052, Australia
CONTRIBUTORS xi
Ross M.G. Norman, Departments of Psychiatry and Epidemiology and Biostatistics,
University of Western Ontario, London Health Sciences Centre, 392 South Street, London,
Ontario N6A 4GS, Canada
Lisa J. Phillips, Coordinator/Psychologist, PACE Clinic, ORYGEN Youth Health and
Department of Psychiatry, The University of Melbourne, Parkville Centre, Locked Bag
10/35 Poplar Road, Parkville, Victoria 3052, Australia
Dr Paddy Power, Lead Consultant Psychiatrist & Honorary Senior Lecturer, Lambeth
Early Onset (LEO) Service, South London and Maudsley NHS Trust, 108 Landor Road,
London SW9 9NT, UK
Dr Ron Siddle, Consultant Grade Cognitive Behaviour Therapist, Manchester Mental
Health and Social Care Trust, Department of Clinical Psychology, North Manchester General Hospital, Delaunays Road, Crumpsall, Manchester M8 5RB, UK
David A. Stayner, Clinical Assistant Professor of Psychiatry, Yale University School of
Medicine and Director of Program Development, Yale Program for Recovery and Community Health, Erector Square, Bldg. #6W, Suite #1C, 319 Peck Street, New Haven, CT
06513, USA
Darryl Wade, Clinical Psychologist, ORYGEN Youth Health, Parkville Centre, Locked
Bag 10/35 Poplar Road, Parkville, Victoria 3052, Australia
Foreword
From its origins in Melbourne over a decade ago, the idea of creating specialized services
for early intervention in psychosis has grown to encircle the globe. It is an idea that has
been actualized in the creation of new service configurations, new psychotherapies and psychotherapeutic perspectives, and a new and growing body of knowledge to inform clinical
care. The idea that new onset psychosis and even pre-illness onset prodromal states might
best be managed in specialized settings and by specially trained teams may in time rank
along with the deconstruction of the asylum as a major turning point in our thinking about
the management of serious mental illness. How has this new therapeutic movement taken
hold so quickly? What are its essential elements?
Two critical observations derived from longitudinal research set the stage for the current
focus on early psychosis. First was the observation that in all societies where investigators
looked, substantial time (12 to 18 months) typically elapsed between the onset of psychotic
symptoms and the time a person found their way to a clinician who could institute appropriate
treatment. Furthermore, many studies seemed to indicate that patients with the longest
duration of untreated psychosis responded more slowly and less completely once treatment
was begun.
Second, modern first-episode psychosis studies established the fact that once patients
with a first psychotic episode were identified and treated, most had a rapid and robust initial
treatment response. Among the most demoralizing findings, however, was the additional
observation that given available treatments and treatment systems, within a year or two the
vast majority of patients went on to suffer a relapse. After the first relapse, once again,
most or nearly all went on to have one or more subsequent relapses. With each turn of
this cycle, the quickness and completeness of treatment response was truncated leaving
clinicians treating these individuals feeling powerless to turn back the tide of what could
sometimes seem like an inexorable march towards chronicity. Based on watching far too
many young persons transformed over the span of a few years into ‘chronic patients’, some
hypothesized that repeated or prolonged periods of psychosis itself heralded a deteriorative
neurobiological process that proceeded irreversibly in only one direction. While research
has not, on balance, upheld a ‘biological toxicity’ hypothesis of prolonged psychosis, it is
clear that by whatever mechanism, prolonged and repeated episodes inflict suffering and
dismantle lives.
Together, duration of untreated psychosis and first episode studies point to an inescapable
conclusion: our health systems fail to get patients with a first episode of psychosis into
treatment and in most instances fail to prevent recurrences and deterioration. It is from the
imperative to do better that early psychosis research and service development derive their
momentum.
As this volume makes clear, psychosocial interventions are at the center of the array of
services that must be developed to create a comprehensive system of care for persons who
have suffered a first episode of psychosis. The treatment approaches described are both
xiv FOREWORD
illness phase-specific, for example focusing on the pre-psychotic phase, first episode, and
first-relapse and individual problem-specific, addressing problems such as co-occurring substance abuse, suicidality, negative symptoms and treatment-resistance. Common elements
of these approaches include a focus on relationship-building and engagement, the flexible
adaptation of techniques to meet individual needs and preferences, the mobilization of families as allies in the treatment effort, and the integration of person-oriented approaches with
current biological understanding of psychosis. Unlike earlier generations of psychological
therapies that rested on endorsement from authorities, the approaches outlined here have
been developed within a framework of evaluation research and evidence-based practice.
While the data are not all in yet, over the next several years we can look forward to
the results of rigorous evaluations or randomized trials to further clarify the utility of these
approaches and guide their refinement and dissemination.
This volume describes work in progress. As a status report from those on the leading
edge of creating and evaluating specialized early psychosis programs, it represents the best
current thinking regarding treatments and treatment systems for young people balanced on
the edge of catastrophe. From theory to practice to evaluation and reformulation of practice
it may be a blueprint for saving lives.
Wayne S. Fenton, M.D.
Bethesda, Maryland