Documenti di Didattica
Documenti di Professioni
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of psychosocial approaches in psychosis has to an understanding of why the person to be very effective for patients with
been accompanied by the development of has developed unusual beliefs; and provid- negative symptoms (Wing & Brown,
staff training courses. The Thorn Nursing ing credible alternative explanations. Speci- 1970). Other simple techniques include
Initiative (Gamble, 1995) was the first sys- fic techniques used to promote engagement activity-scheduling, rating mastery and
tematic training course for mental health include using the patient’s own words, pleasure, and social skills training (Hogg,
professionals working in the community. agreeing to disagree, avoidance of jargon 1996).
Good outcomes included reductions in and accepting the unlikely as possible but
positive symptoms and an improvement in unlikely, all of which supplement the Early warning signs
social functioning (Lancashire et al,
al, 1997). general techniques of warmth, empathy
Many individuals can identify their own
There is still a lack of such training in and unconditional positive regard. Tailor-
idiosyncratic, prodromal signs of relapse.
institutional settings, and recent concerns ing the therapy to the patient’s particular
It is useful to map the exacerbation of
have been expressed in The National Visit needs may include short, frequent sessions.
symptoms and correlate these with poten-
regarding the deficiencies of care within The use of a normalising rationale, which
tial personal and environmental stressors
in-patient settings (Sainsbury Centre for reframes a person’s psychotic experiences
that may precipitate deterioration. Birch-
Mental Health & Mental Health Act into understandable and explainable terms,
wood et al (1989) used early warning sign
Commission, 1997). reduces the anxiety and distress associated
questionnaires with patients and staff.
As a result of high expressed emotion with psychotic symptoms.
Patients can often link feeling worse, or
attitudes found in nurses working with
being more concerned about their psychotic
patients with chronic psychosis (Herzog,
Positive symptoms symptoms, with environmental factors.
1998), training within in-patient settings
has been undertaken. Finnema et al Treatment for positive symptoms is well
(1996) found that their programme led to researched and has been described else- Dealing with hopelessness
general changes in the ward atmosphere, where in detail (Chadwick et al, al, 1996; Clozapine-resistant patients generally have
such as a decrease in ‘ward rules’. We have Dickerson, 2000) and therefore will not long psychiatric histories. They have
used a combined psychoeducational and be covered in depth here. However, because received many psychotropic drugs and
therapeutic training approach, which negative symptoms and thought disorder often have lost faith in medication. Cloza-
produced positive results on levels of are often more problematic in this patient pine may be described as the last chance
knowledge and stress among staff (further group, their treatment has been described. of obtaining relief from psychotic symp-
details available from the author upon toms, and the patient may have high expec-
request). Therapy for thought disorder tations. If clozapine fails to ‘live up to
Working with patients with thought dis- expectations’, a sense of hopelessness may
order is challenging, but there are tech- be generated. Therefore, it is particularly
Working with individuals important to deal with such feelings in
niques that may be helpful, such as
General principles patients, families and carers, as well as with
keeping sessions short. Just spending time
In the past it was thought that psychological with the person is important, as he or she the negative impact on the person’s self-
therapies were contraindicated in psychosis, may have had many years of not being esteem.
but studies such as the London–East Anglia understood and being avoided by others.
study (Garety et al,al, 1997; Kuipers et al,al, Themes emerge in apparently unintelligible Compliance therapy
1997, 1998) have shown that this is not speech during regular sessions, and tape- Kemp et al (1998) conducted one of the few
the case, with good outcomes following recording can help. Once themes have been randomised controlled trials of compliance
9 months of therapy and at 18-month identified, the patient is helped to focus on therapy for patients with mental health
follow-up. In addition, for both positive them in a structured way before moving on problems. Although the intervention was
and negative symptoms of schizophrenia to problem-solving, reframing or reality- complex, it led to improvements in insight,
there is good evidence to support psycho- testing where appropriate. If able, the attitude to medication and compliance.
logical approaches, such as manualised person may get some control over his or However, there was little effect on func-
cognitive–behavioural therapy (Sensky her speech by writing the thoughts down. tioning. Important components include:
et al,
al, 2000). Usually, a lengthy assessment
conceptualising the problem, focusing on
period is required before a detailed formula-
Negative symptoms symptoms and side-effects, exploring bene-
tion can be developed. This should lead to
fits and drawbacks of treatment, exploring
specific interventions related directly to the Careful assessment of negative symptoms is
ambivalence, highlighting discrepancies
formulation. However, those patients who required, because they are likely to co-exist
between actions and beliefs, focusing on
are resistant to clozapine are among the with other problems, such as side-effects of
adaptive behaviours, encouraging self-
most severely disabled, both socially and medication, depression or institutional-
efficacy, and emphasising the value of stay-
emotionally, and any psychosocial strategy isation. The pace of the interview needs to
ing well and the importance of treatment.
undertaken will require a flexible approach. be slow, to give the patient time to respond.
Clear, simple, open questions will promote
the development of the therapeutic relation- Working with families
Engagement ship, and writing down key points can help Family interventions are effective in redu-
Kingdon & Turkington (1998) describe the patient to recall the sessions. Modifi- cing the likelihood of relapse in psychosis.
two components to engagement: coming cation of the environment has been shown Early work examined the association
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WILLIAMS E T AL
between high expressed emotion among patients who are resistant to clozapine Predictors of outcome. British Journal of Psychiatry,
Psychiatry, 171,
171,
420^426.
caregivers and poor clinical outcome monotherapy, justifying a more positive
following discharge (Vaughn & Leff, approach. Gupta, S., Sonnenberg, S. J. & Frank, B. (1998)
Olanzapine augmentation of clozapine. Annals of Clinical
1976). Manualised approaches to family
Psychiatry,
Psychiatry, 10,
10, 113^115.
work are now available (Barrowclough & DECLAR ATION OF INTEREST
Herzog, T. (1998) Nurses, patients and relatives: a
Tarrier, 1992). Key features of such inter-
study of family patterns on psychiatric wards. In Family
ventions include education, enhancing pro- None. Intervention in Schizophrenia: Experiences and Orientation
blem-solving and coping strategies and an in Europe (eds C. L. Cazzullo & G. Invernizzi). Milan:
emphasis on communication styles between ARS.
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