The Perceptions of Psychosocial Interventions among Individuals with a First Episode Psychosis: A Qualitative Study
Background
Psychosocial Interventions are part of an evidence based treatment package for people with a first episode psychosis in Early Intervention Services. Experiencing psychosis for the first time can be a distressing and confusing time, which carries a one hundred times greater risk of suicide, so prompt and effective treatment is vital to reduce risk and produce good outcomes. Although there is much research about the efficacy of various psychosocial interventions, there is very little exploration of service user’s experience of these interventions and whether they aid understanding and sense making. This study aimed to explore the perceptions of service users to the KGV assessment, the stress vulnerability model and timelines, all of which we tend to use early on in the assessment and treatment of psychosis.
Methods
The study used a purposive sample of four people who had been with the Early Intervention Service for between three and six months, all had experience of the psychosocial interventions which were under investigation. The data was collected by use of semi structured interviews which were recorded on a digital recorder.
All interviews were transcribed, coded and analysed using thematic analysis. Three themes and six sub themes were generated. The first theme was distress and included subthemes of impaired functioning, not knowing and the burden of symptoms. The second theme was help seeking which included subthemes of gaining control and understanding / making sense. The final theme was recovery and included the subtheme of self-management.
Results & Discussion
The results found that the participants spoke of initial distress of psychotic symptoms, this was encapsulated by not knowing what the symptoms were, having functioning impaired by the symptoms and trying to cope with the burden of the symptoms. This distress motivated some of the participants to seek help which helped them to gain control of the symptoms and to begin to understand and make sense of them.
However differences in coping styles were highlighted which had a direct impact on the participant’s experience of mental health services and the interventions offered to them. Participants who showed a more integrative style of coping were able to move through the recovery journey more smoothly, while those that sealed over were less likely to perceive psychosocial interventions as helpful. Other differences were in the way participants had come in to contact with services, those who had sought help for themselves had a more positive view of services than those who had been detained under the Mental Health Act. An important part of recovery was the therapeutic relationship and the skills of clinicians in attending, opening a narrative about a person’s experience, and listening.
Conclusion
There are five main variables which affect a person’s perceptions of the psychosocial interventions offered to them; these are;
Coping style
This is the way an individual deals with the psychotic experience they have had. Coping styles are split in to two groups although often not as clear cut as they initially seem. There are integrators these are individuals who place the psychosis within the context of their lives and try to understand and learn from it, these people will be willing to talk about and explore their experiences. Then there are sealors, these are the people who put the psychotic experience in a mental box and close the lid. They may be unwilling to discuss their experiences wanting instaed to move on with their lives as if the psychosis didn’t happen. The reason coping style is important is that it will influence how people perceive psychosocial interventions and how they engage with mental health services.
Symptoms that are being experienced
A high level of psychotic symptoms can potentially make it difficult to engage therapeutically with the psychosocial interventions offered. The study highlighted that participants who were experiencing more psychotic symptoms found it more difficult to make sense of their experiences, but that isn’t to say it was impossible.
Many symptoms of co morbidities such as anxiety and depression were also affecting participants ability to recover and re-engage with their lives, and utilise psychosocial interventions. Many participants spoke of high levels of anxiety that affected their ability to socialise and sometimes even to perform tasks they had previously taken for granted such as going shopping this in turn affected self-esteem and confidence and re gaining these was also an important part of the recovery journey.
Relationship with mental health services
Peoples relationship with mental health services will play a significant role in their perceptions of the interventions they are offered. If they feel they are able to trust and rely on the service then their willingness to engage will be good. One of the helpful factors in engaging with services seems to revolve around clinicians being there, being knowledgeable, and having the skills to establish a good therapeutic relationship. The importance of this therapeutic relationship underlies all good mental health practice and the skills of clinicians at building trust and rapport and opening up a narrative in order to explore and understand experiences is the cornerstone to this. People with a first episode of psychosis are more likely to find it hard to engage in psychosocial interventions or recovery if they do not have this relationship with the clinicians who are supporting them. The study highlighted the importance of attending and being able to actively listen as well as being knowledgeable and being able to educate people about the experiences they were having.
Place in Recovery Journey
For many reasons people will be at different places in their recovery journey; it is a personal journey which should be guided by and not judged by clinicians. However this study does show that depending on where this place is should shape the interventions we offer and the care we provide, early intervention is not a one size fits all service and to be truly effective interventions need to be individualised, personal and meaningful
How they Entered Mental Health Services.
The level of distress experienced by all participants when they developed psychosis was initially high, for some this had motivated them to seek help for their mental health difficulties. But others had to be treated against their will under the Mental Health Act. The participants who sought help felt more in control of their experiences. They were more able to embrace the psychosocial interventions they were offered and gain some knowledge and understanding from them. There were marked differences with the participants who had visited their GP’s themselves and the participant who was detained under the mental health act.
The five variables outlined above are all closely linked.
Recommendations for Practice
These five variables will influence help seeking and recovery, if we hold them in mind when we initially meet people it may be that they shape the way we offer psychosocial interventions. This model can also guide us when thinking about where are priorities should be for example if someone has a poor relationship with mental health services because of a distressing hospital admission then our focus should be on building the therapeutic relationship either before or while we also offer psychosocial interventions. A good therapeutic relationship may alter the way in which a person with a first episode psychosis perceives psychosocial interventions. It may be that the person has more urgent needs that take priority and help to strengthen the therapeutic relationship like housing and financial needs and if these aren’t met then focusing on psychosocial interventions may not be successful. Within the research this is explored by using the framework of Malsow’s hierarchy of needs.
There is an expectation that psychosocial interventions are offered to everyone within early intervention teams as early as possible, however this research suggests that this may need to be on a much more individual basis for it to be effective, as people’s perceptions of these interventions will depend on the five variables outlined in the model. This paper also raises the question of whether we should be assessing these five variables as a routine part of our assessment.
This study highlights the reasons why people’s perceptions of interventions may vary and could begin to guide us when thinking about the type of interventions we are offering people who have different ways of coping and processing their experiences.
Influences this may have on local practice
From April this year our NHS Trust (AWP) has set targets that all referrals to our service should be seen assessed and offered a package of psychosocial interventions as well as various other appropriate treatment within two weeks. Although this is being done to ensure young people are seen and treated in a timely manner it does not take in to account any of the variables that were identified in this study. People may reject psychosocial interventions when they initially meet us and this may be for any of the five identified variables, however once we are able to build a therapeutic relationship with them, this may change. Obviously we would want to able to offer a flexible package of care and to enable young people to access these interventions whenever they need to and at a time when it would be most useful to their recovery journey. I have already discussed this within my team in Wiltshire, and will be bringing it to our next Early Intervention Network day, which covers all the Early Intervention Teams within the catchment area of AWP NHS Trust. I am hoping to initiate a discussion on this which we can then move forward, and potentially discuss with the commissioners, so that our targets are flexible and patient led.