Therapy for schizophrenia

[LadyHalcyon]

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Any experiences working with active psychosis? I have a patient who is actively psychotic, has a prior diagnosis of schizophrenia, and is only being prescribed copious amounts of benzos. He cannot get into see the psychiatrist for another month. What could be helpful, therapeutically speaking, for this client? I'm not sure who the genius was that came up with reality testing..... Maybe they didn't realize delusional beliefs are somewhat juxtaposed with logical beliefs

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[PsyDr]

Donald turkinton published on CBt for schizophrenia. Briefly: ask pt about the content, volume, and frequency unit auditory hallucinations. Thenfocus pt on an external stimulus (I believe he has pt describe the nuances of a painting, iirc). Ask pt if volume of voices change. It does. Use that for a discussion about how some, not all, aspects of auditory hallucinations are under pts control.

 

[Justanothergrad]

My experience with schizophrenia (about a year full time on an ACT team) has been that my role became a much greater blend of case management and therapy rather than simple, direct psychotherapy. Focusing on stress management and helping to plan out events to increase social support, interactions, put off things that are stressful which can be dealt with in a month, etc were a big part of helping to decrease episode frequency/severity. Then there was skill building as PSYDR mentioned for when those efforts were insufficient.

 

[LadyHalcyon]

Donald turkinton published on CBt for schizophrenia. Briefly: ask pt about the content, volume, and frequency unit auditory hallucinations. Thenfocus pt on an external stimulus (I believe he has pt describe the nuances of a painting, iirc). Ask pt if volume of voices change. It does. Use that for a discussion about how some, not all, aspects of auditory hallucinations are under pts control.

Thanks. I'll look into it. I kind of did some form of what you described today. What's interesting is that the patient is aware enough to realize he has to conceal his behavior and beliefs from others. For example, he says he no longer talks to himself aloud because people thought it was strange. Now, he speaks to himself silently

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[StellaB]

Thanks. I'll look into it. I kind of did some form of what you described today. What's interesting is that the patient is aware enough to realize he has to conceal his behavior and beliefs from others. For example, he says he no longer talks to himself aloud because people thought it was strange. Now, he speaks to himself silently

That's not terribly uncommon for schizophrenia, particularly if this person is organized enough to be coming to therapy and seeking help. Even with psychotic symptoms, a lot of people who suffer from schizophrenia remain cognizant of other people's reactions to them, and typically try to hide the behavior that prompts those reactions. I second the CBTp approach, and coaching social skills, which it sounds like you are doing. There are also some fairly good resources on the internet for coping with auditory hallucinations that might be helpful to your client in the meantime. Coping with Voices - Living With Schizophrenia

 

[AcronymAllergy]

Did a bit in grad school with group-based social skills training, and group and individual substance use treatment in SMI at a community mental health clinic. Both had positive, albeit limited, outcomes for many of the folks involved. At least based on what we were able to see, and what they reported.

 

[G Costanza]

Isn’t family therapy the best option if there are willing participants?

 

[LadyHalcyon]

Isn’t family therapy the best option if there are willing participants?

Unfortunately that isn't an option. Medicaid won't pay

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[Justanothergrad]

Unfortunately that isn't an option. Medicaid won't pay

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Another thought, I haven't done any work with it but I know that ACT has also had some good results as I recall (if folks get tired of the CBT approach). I know there is some good outcomes associated with that approach as well. May be worthwhile if you can pull the fam. / sig. other in for psychoeducation and discussions of how to monitor symptoms for part of the session. You should be able to bill that under individual without an issue.

 

[LadyHalcyon]

Another thought, I haven't done any work with it but I know that ACT has also had some good results as I recall (if folks get tired of the CBT approach). I know there is some good outcomes associated with that approach as well. May be worthwhile if you can pull the fam. / sig. other in for psychoeducation and discussions of how to monitor symptoms for part of the session. You should be able to bill that under individual without an issue.

That is true, that is a billable service. Good idea!

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[psych.meout]

What about MERIT or some other meta-cognitive therapy.

 

[LadyHalcyon]

What about MERIT or some other meta-cognitive therapy.

Never heard of it but I will look into it. Thanks!

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[cara susanna]

There's some good research backing ACT as a helpful intervention for schizophrenia. Worth look into, at least.

 

[LadyHalcyon]

There's some good research backing ACT as a helpful intervention for schizophrenia. Worth look into, at least.

Thanks!

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[AnnoyedByFreud]

Depending on the severity of psychosis, adverse effects it could have on the patient's life, etc., you might want to consider encouraging the patient to go to the hospital to get stabilized rather then having them decompensate potentially for weeks.

 

[LadyHalcyon]

Depending on the severity of psychosis, adverse effects it could have on the patient's life, etc., you might want to consider encouraging the patient to go to the hospital to get stabilized rather then having them decompensate potentially for weeks.

This is my concern too, especially considering he is meeting with me as a requiremen of his federal and state probation. Currently he is not endorsing any si/hi but he does seems to be decompensating
He won't got to the hospital voluntarily so I would have to pink slip him and he doesn't truly meet the criteria

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[futureapppsy2]

This is my concern too, especially considering he is meeting with me as a requiremen of his federal and state probation. Currently he is not endorsing any si/hi but he does seems to be decompensating
He won't got to the hospital voluntarily so I would have to pink slip him and he doesn't truly meet the criteria

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Have you considered doing motivational interviewing to encourage him to reconsider voluntary hospitalization? Seconding the acceptance and commitment therapy suggestion as well...

 

[LadyHalcyon]

Have you considered doing motivational interviewing to encourage him to reconsider voluntary hospitalization? Seconding the acceptance and commitment therapy suggestion as well...

No not yet. I convinced him to see our psychiatrist, which was difficult because he says he has severe allergies to certain medication
The cmhc I'm at does the genetic mouth swab test so he agreed to that. He has a fear of being poisoned and I think that is why he is hesitant to meds. BUT he said he liked what they gave him in prison so I requested those records and just got them back. He believes the drug he liked was Risperdal. We shall see.

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[ela]

Compassion for voices....consistent with an ACT approach.

 

[smalltownpsych]

Any experiences working with active psychosis? I have a patient who is actively psychotic, has a prior diagnosis of schizophrenia, and is only being prescribed copious amounts of benzos. He cannot get into see the psychiatrist for another month. What could be helpful, therapeutically speaking, for this client? I'm not sure who the genius was that came up with reality testing..... Maybe they didn't realize delusional beliefs are somewhat juxtaposed with logical beliefs

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I wouldn't worry too much about treating or even addressing the psychosis. As mentioned previously, if the patient is being bothered by the voices, help them to learn how to distract. Also, you can help them differentiate between your voice and their voices. They can tell you are real because they can see you. Talk about concrete things that are going on in their life. Don't talk to them about the psychotic content, redirect to something more practical and present-based. Use empathic responding to address delusions such as when the patient has persecutory delusions just say I can see that you are really scared or something appropriate along those lines and then shift to something concrete that they might be anxious about. If patient is paranoid about being poisoned, then the shift could be along the lines of fears of medication not working or having negative side effects. Working with psychotic patients is very difficult but can be very rewarding when you start to develop some skill. Good supervision is essential. I am just trying to throw out a few quick tips but would need a few weeks of hour long supervisions to really be able to help. Also, rapport is key. It always is but even more so with someone who is psychotic and it can be harder to develop. Be patient. Don't try to help as much as just try to develop a connection. Hope some of this helps.

 

[LadyHalcyon]

I wouldn't worry too much about treating or even addressing the psychosis. As mentioned previously, if the patient is being bothered by the voices, help them to learn how to distract. Also, you can help them differentiate between your voice and their voices. They can tell you are real because they can see you. Talk about concrete things that are going on in their life. Don't talk to them about the psychotic content, redirect to something more practical and present-based. Use empathic responding to address delusions such as when the patient has persecutory delusions just say I can see that you are really scared or something appropriate along those lines and then shift to something concrete that they might be anxious about. If patient is paranoid about being poisoned, then the shift could be along the lines of fears of medication not working or having negative side effects. Working with psychotic patients is very difficult but can be very rewarding when you start to develop some skill. Good supervision is essential. I am just trying to throw out a few quick tips but would need a few weeks of hour long supervisions to really be able to help. Also, rapport is key. It always is but even more so with someone who is psychotic and it can be harder to develop. Be patient. Don't try to help as much as just try to develop a connection. Hope some of this helps.

Thank you so much. All of that was extremely helpful! This is my first year working with this population and at times it can be a struggle to build and maintain rapport. That being said, I'm glad for the exposure I have had this year; it's definitely been a challenge!

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[Oliver3838]

Any experiences working with active psychosis? I have a patient who is actively psychotic, has a prior diagnosis of schizophrenia, and is only being prescribed copious amounts of benzos. He cannot get into see the psychiatrist for another month. What could be helpful, therapeutically speaking, for this client? I'm not sure who the genius was that came up with reality testing..... Maybe they didn't realize delusional beliefs are somewhat juxtaposed with logical beliefs

It would take further training (a certificate at least) but there is a form of psychoanalysis adapted for schizophrenia and/or narcissistic defenses called Modern Psychoanalysis (there are centers in New York, Philadelphia, and I believe Boston and Boulder at least).

 

[LadyHalcyon]

It would take further training (a certificate at least) but there is a form of psychoanalysis adapted for schizophrenia and/or narcissistic defenses called Modern Psychoanalysis (there are centers in New York, Philadelphia, and I believe Boston and Boulder at least).

Thanks for the suggestion!

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