Addressing the Trauma of First Episode Psychosis

1. Addressing the Traumaof First Episode Psychosis Stephanie Hurley, MA, LPCC-S-Greater Cincinnati Behavioral Valerie Krieder, PhD, LPCC-S, LICDC-CS, BeST Center Heather Pokrandt, MSW, LISW-S, BeST Center, NEOMED

2. STORY FROM THE FIELD Phoenixsociety.org

3. TRAUMA BASICS -SAMHSA

4. FIRST EPISODE PSYCHOSIS BASICS • Commonly referred to as FEP • Refers to the first time someone experiences psychotic symptoms or a psychotic episode • The word psychosis is used to describe conditions that affect the mind, where there has been some loss of contact with reality. • People experiencing a first episode may not understand what is happening • Symptoms can be disturbing and unfamiliar, leaving the person confused and distressed NIH, 2015; Yale School of Medicine, 2017

5. FIRST EPISODE PSYCHOSIS BASICS • Often begins when a person is in their late teens to mid-twenties • Three out of 100 people will experience psychosis at some time in their lives • About 100,000 adolescents and young adults in the US experience first episode psychosis each year • Psychosis affects people from all walks of life. NIH, 2015; Yale School of Medicine, 2017

6. FIRST EPISODE PSYCHOSIS BASICS • Can include: • Hallucinations (seeing, hearing, smelling, tasting or feeling something that is not real) • Paranoia or delusions (believing in something that is not real even when presented with facts) • Disordered thoughts and speech • Unfortunately, negative myths and stereotypes about mental illness and psychosis in particular are still common in the community NIH, 2015; Yale School of Medicine, 2017

7. FROM THE FIELD • Despite extensive trauma histories that include physical, sexual, or emotional abuse, abandonment, sexual assault, homelessness, and myriad other experiences, every client identified their initial hospitalization for psychosis as their most stressful experience • Initial hospitalizations were often involuntary, and may have included forcible removal from their homes and even being tased by police • Clients often have persistent anger, paranoia, and distrust toward family members who initiated the hospitalization

8. PREVALENCE shutterstock_249397189

9. PATIENT-PERCEIVED EFFECTSof psychotic illness • Disintegration: perceived lack of control over one’s self and one’s interaction with others due to psychotic symptoms • Stigma • Self-stigma • Stigma from others • Estrangement: feelings that people did not understand or relate to the illness experience and were unable to provide support • Sense of loss and deficit • Recognizing the illness as an ongoing problem Dunkley et al., 2015

10. PATIENT-PERCEIVED CONSEQUENCESof psychiatric care treatment • 80% felt traumatized by their treatment • Potential iatrogenic effect of psychiatric care • “inadvertently introduced” • Since suicidal behavior is significantly associated with the experience of trauma, interventions need to reduce traumatization and suicide risk Dunkley et al., 2015 Tarrier et al., 2007

11. ASSESSMENT PTSD Checklist for DSM-5 (PCL-5) • Designed as a screening instrument – from the Veteran Administration’s National Center for PTSD • Assists in identifying stressful experiences and any bothersome responses (even those not meeting PTSD diagnostic criteria) • Assists with monitoring changes in symptom distress

12. ASSESSMENT – PCL-5 • The PCL-5 is a 20-item self-report measure • Assesses the 20 DSM-5 symptoms of PTSD scored from 0 to 4 • It takes approximately 5-10 minutes to complete https://www.ptsd.va.gov/professional/assessment/adult-sr/ptsd-checklist.asp

13. PCL-5 • Scoring is relatively simple by summing the total of the 20 items • Score of 38 or higher means a stressful experience has had a significant impact on a person-recommend to meet with therapist to process the experience & symptoms, and develop coping strategies • FROM THE FIELD: Many clients struggle with completing the measure - important to develop trust and rapport

14. ASSESSMENT The gold standard for diagnosing PTSD is a structured clinical interview such as the Clinician-Administered PTSD Scale (CAPS-5) • When necessary, the PCL-5 can be scored to provide a provisional PTSD diagnosis by treating each item rated “Moderately” or above as symptomatic, then following DSM-5 diagnostic criteria

15. INTERVENTIONS Should address past, current, and ongoing traumatization Should integrate hope and empathy Should assist in overcoming perceived barriers to recovery

16. FROM THE FIELD • Care is given to avoid use of the word “trauma” to be more inclusive with all client self-perceptions • Key take away is that what clinicians thought would be each client’s most stressful experience or trauma often did not match the client’s identified most stressful event • Through identification of the most bothersome symptoms of stressful experiences, clinicians help client learn targeted coping strategies

17. TRAUMA-INFORMED CARE

18. GENERAL COPING STRATEGIES • Use relaxation techniques such as relaxation breathing, muscle relaxation, or imagining a peaceful scene • Use of Cognitive Restructuring- recognizing self-defeating thinking styles and replacing negative beliefs about oneself, others, and the world • Talk to a supportive person about thoughts and feelings, develop a crisis plan • Use of positive self-talk - focus on accomplishments • Exercise-elevates mood, changes focus, reduces anxiety, and exercising with friends increases social support

19. INTERVENTIONS MINDFULNESS • Mindfulness is simply a way of paying attention. • The goal is not to "not think" • It is a way of paying attention to something “choicefully,” without judgment, with gentleness and compassion • Often attending to the breath is the best way to start. • After all, your breath is with you where ever you go, so you can practice mindfulness to breath wherever you go.

20. INTERVENTIONS MANY KINDS OF MINDFULNESS Generally, getting used to "Mindfulness to the Senses" is very grounding and is an excellent place to begin: • Breath • Listening/hearing (music, sounds from the environment) • Touch (favorite fabric, smooth stone, favorite object) • Smell (aromatherapy) • Taste (eating, savoring, anchoring) • Sight (photographs, paintings, whatever is available in the environment) • Self soothing kit

21. INTERVENTIONS MEDITATION • Meditation has been found to make the body behave in the opposite way that trauma does • Slows heart rate • Slows breathing • Blood pressure normalizes • Oxygen is used more efficiently • Cortisol, adrenaline, and noradrenalin production reduces • It has been found that people who meditate are more easily able to give up old coping skills in favor of more effective coping skills Curran, L. (2010). Trauma Competency; A Clinicians Guide. Eat Clair, Wisconsin.

22. EACH ONE TEACH ONE

23. INTERVENTIONS COGNITIVE BEHAVIORAL THERAPY FOR PSYCHOSIS • Engagement - process is long and slow • Building a strong and trusting relationship is the most important factor • START – Early and Late depending on stage of therapy

24. INTERVENTIONSCOGNITIVE BEHAVIORAL THERAPY FOR PSYCHOSIS • Distraction • Exercise • Playing music • Social Activities • Concentration • Mindfulness activities • Artwork • Reading a book • Doing a puzzle • Cognitive approaches • Reality testing • Changing our relationship with the voices • Changing our belief about the voices • Keeping a voice diary, and reviewing it with a counselor • Normalize • Famous voice hearers

25. Interventions Coordinated Specialty Care for First Episode Psychosis • Includes all of these interventions in a team-based care model • Evidence-based and resiliency-focused • Specialized, Coordinated System of Care • Weekly treatment team meetings • Includes Supported Employment and Education Services • Psychoeducation • Empowerment • Shared Decision Making • Family/support persons part of the treatment team

26. EMPATHY - A GREAT START

27. EMPATHY CONCEPTUALIZED • Perspective Taking • Staying Out of Judgment • Recognizing Emotion in Other People • Communicating that Recognition Rarely can a response make something better. Connection is what does that because healing happens in relationship.

28. CONTACT US! Best Practices in Schizophrenia Treatment (BeST) Center http://www.neomed.edu/bestcenter/ 330-325-6695 Greater Cincinnati Behavioral Health Services https://www.gcbhs.com/ 513-354-7213