Novel Psychological Approaches: Five Notable Developments in the Past 10 years

1. Novel Psychological Approaches: Five Notable Developments in the Past 10 years Cori Cather, PhD Massachusetts General Hospital/Harvard Medical School1 Assistant Professor of Psychology Department of Psychiatry Massachusetts General Hospital/Harvard Medical School

2. 1998 Patient-Outcomes Research Team (PORT) Recommendation Warning Lehman et al. (1998), Schiz Bull

3. Page Length of Psychosocial Treatment Recommendations Number of Pages Dixon et al., 2010, Schiz Bull

4. 2009 Patient-Outcomes Research Team (PORT) Recommendations • Assertive Community Treatment • Supportive Employment • Skills Training • Cognitive Behavioral Therapy • Token Economy Interventions (inpatient) • Family-Based Services • Integrated Dual Diagnosis Treatment • Weight Management

5. #1: Dissemination of an Effective Family Intervention

6. NAMI Family to Family (FTF) • 12-week structured program run by trained peers • Education, self-care, communication and problem-solving skills and understanding of their emotional response to mental illness • Available in 49 states, Puerto Rico, and parts of Mexico, Canada, and Italy • Free of charge • Since 1991, over 3500 participants in the US

7. Outcomes of a NAMIs FTF program vs. Wait-list Control (n = 318) Effect Size (d) Dixon et al (2011). Psych Serv

8. #2: Interventions for Cognitive Impairment

9. 9 month home-based Direct observation of skill assessed Targets hygiene, dressing, diet, treatment adherence, etc. Environmental manipulations (e.g., checklists, florescent signs, photos) Redundant systems (e.g., calendar posted on fridge and in cell phone, back up alarms) Establish routines to decrease cognitive load Effective, but not durable once intervention is removed 3-6 months 3-5x/week Computer-based training exercises Can include strategy coaching Small effects on cognitive functioning, symptoms and general functioning One study showed associations between increased gray matter and cognitive improvement in patients early in course of illness Compensatory Restorative CAT: Cognitive Adaptation Training Cognitive Remediation McGurk et al. (2007) Am J Psych Eack et al (2010) Arch Gen Psych. Draper et al. (2009) J Clin Psych: In Session

10. #3: CBT: A Shift in Focus to Negative Symptoms and Functioning

11. Identification ofCognitive Underpinnings of Negative Symptoms Low expectancies of pleasure “I won’t enjoy it.” Low expectancies of success “I won’t know what to say.” High perception of limited resources “It will take a lot of energy to do it.”

12. 60 patients with schizophrenia and significant cognitive impairment 18 months of recovery-oriented CBT vs. TAU CBT superior effects on: General functioning Energy, drive, interest Psychotic symptoms CBT: Focus on Functioning Grant et al., 2012, Arch Gen Psych

13. #4: Acceptance, Mindfulness, Resilience, Self-Esteem

14. Acceptance, Mindfulness, Resilience • Awareness of psychosis • Allow psychosis to come and go without reaction or struggle; thought suppression and the assumption that all thoughts must lead to action are at root of psychopathology • Compassion to self • Acknowledge and develop strengths and what is good • Take control of making one’s life better

15. Acceptance and Commitment Therapy (ACT) (N = 80) • Acceptance and experience of thoughts and feelings • Half the hospitalization rate in the 4 month f/u in ACT • ACT group more open about psychotic symptoms Bach and Hayes, 2002, JCCP

16. Negative Secrecy Information management Overcompensation Positive Positive in-group stereotyping—”People with mental illness are more caring.” Humor Community involvement Protecting Self-Esteem • Neutral • Selective Social Comparison—”Things are better than 20 yrs ago..” • Normalization—”Some people have a physical illness…” • Information Seeking Ilec et al, 2011. Intl J of Social Psych

17. #5: Development of Multi-component First Episode Programs

19. #5: CBT for Individuals at High Risk for Psychosis

20. GOALS: Delay or prevent transition to frank psychosis Reduce duration of untreated psychosis INTERVENTIONS: Address cognitive biases (e.g., selective attention to threat, jumping to conclusions, covariance bias) Improve functioning Decrease cannabis use CBT for Those at High Risk

21. Can CBT in High Risk Patients Prevent Transition to Psychosis? (N = 48) Percent transition at 1 yr Morrison, AP et al. (2004)

22. Can CBT in High Risk Patients Prevent Transition to Psychosis? (N = 196) Percent transition at 18 mos Van der Gaag et al. (2012) Schiz Bull

23. Clinical Program at MGH to Promote Resiliency for Siblings and Individuals at Risk8-week course focused on stress reduction, interpersonal effectiveness, mindfulness, increasing everyday pleasure, well-beingFor more information, call:617-724-2931

24. Future Directions • Dissemination • Psychosocial treatments for cognitive impairment and negative symptoms • Mindfulness, acceptance, resiliency, and peer support • Quality care in first episode and early psychosis to reduce disability • Interventions for those identified as at risk