Better outcomes for schizophrenia:

a patient-centred approach

Thursday 7th November 2019

Tonight’s panel

Dr Cathy Andronis

General Practitioner

Russell

Lived Experience

Advocate

Dr Richard Lakeman

Mental Health Nurse

Facilitator:

Julianne Whyte

Mental Health

Social Worker

Dr Melissa Connell

Psychologist

Learning outcomes

Through an exploration of schizophrenia the webinar will provide participants with the opportunity to:

• Describe the common symptoms and causes associated with schizophrenia

• Identify the challenges, merits and opportunities in evidence-based approaches deemed most effective in

treating and supporting people experiencing schizophrenia

• Facilitate clinical and personal recovery in a primary care setting for people who may experience psychosis or be

diagnosed with schizophrenia.

Believe

Russell

Surround yourself with people that believe in the same thing:

• Be it your doctor or health professionals or even the church

Believe in the medication:

• Take your medication religiously and seek support if you need.

Acceptance

Russell

• Accept the illness and love yourself warts and all

• Having acceptance that you have a medical condition means you have a greater insight into what most

others don’t

• The weakness is also a strength. You can gain valuable insight from others whom are willing to help you.

Think of it as personal coaching or mentoring.

Ups and downs

Russell

Even the biggest of ships will self-right if tipped:

• Always know if things do go pear shaped, life cycles will always fix things naturally and without trying too hard

for perfectionism

Sometimes just thinking of a favourite food helps take the edge off difficult times when you need to feel

grounded within yourself

Plan where you will sit at Christmas or family gatherings:

• Often these times are the hardest so fit yourself in by contriving a comfortable place for yourself.

Diagnosis and aetiology of schizophrenia

Dr Cathy Andronis

DSM5

Two or more of the following for at least a one-month, and at least one of them must be 1, 2, or 3:

• Delusions

• Hallucinations

• Disorganised speech

• Grossly disorganised or catatonic behaviour

• Negative symptoms, e.g., reduced emotional expression

• Impairment in one of the major areas of functioning for a significant period of time since the onset of the

disturbance: work, interpersonal relations, or self-care

• Overall symptoms / reduced functioning at least 6 months.

Schizoaffective disorder and bipolar or depressive disorder with psychotic features have been ruled out:

• Causes

• Genetics

• Environment

• Brain chemistry

• Substance use

Common symptoms and challenges associated with schizophrenia

Dr Cathy Andronis

• Diagnosis is often unclear and uncertain – it is common to receive multiple or provisional diagnoses over time,

especially for chronic presentations

• Diagnostic uncertainty is distressing for patients and stigmatising

• GPs are sometimes placed in a “double bind” - they must label patients in order to prescribe some medications or

treatments or prepare plans (PBS, Medicare) but they need to remain sensitive to the patient’s needs and concerns

• Cynthia is a fairly typical patient but everyone has their unique story and GPs are expert at individualised patient

care – this is optimised by continuation of care and developing a trusting relationship between doctor and patient.

Patients who have a regular, reliable GP have best outcomes

• Multiple challenges, merits and opportunities in evidence-based approaches deemed most effective in

treating and supporting people experiencing schizophrenia.

Good engagement with usual GP on a regular basis, important for:

Dr Cathy Andronis

• Managing negative symptoms especially poor motivation, social withdrawal / isolation

• Also issues of anxiety, ambivalence, stigma

• Active follow up and engagement is a whole of practice approach (safety netting)

• Multidisciplinary care and GP awareness of local services is vital. Regular communication between the GP and

other providers improves outcomes and results in better support of the providers as well as the patient

• Facilitating clinical and personal recovery in a primary care setting for people who may experience

psychosis or be diagnosed with schizophrenia

• Treat the patient not the disease.

The holistic approach

Dr Cathy Andronis

• GPs often understand the patient’s context and may know their family or other supports. This is helpful in avoiding

isolation but also for appreciating triggers or assessing risks

• Supportive long term care and counselling with a familiar GP is sometimes the only trusted provider for some

patients and at some stages of their life

• Patients with a schizophrenia diagnosis do benefit enormously from regular contact and counselling with FPS

providers and are usually capable of engaging with all FPS modalities with a trusted therapist

• Building engagement slowly and patiently, making allowances for negative symptoms and avoiding judgements is

critical.

The role of the psychologist on the treating team

Dr Melissa Connell

The value of psychological approaches to psychosis:

• develop self understanding and effective coping strategies

• reduce reliance on medications

• avoid hospital admissions

• support recovery

Referral and access to psychologists:

• Better Access

• NDIS

• private health insurance

• mental health services

History, assessment and formulation

Dr Melissa Connell

History:

• developmental history

• time-line (what’s happened and how it has affected Cynthia)

• stress-vulnerability model

• Assessment tools (e.g. PSYRATS, Maastricht Interview, BPRS)

Collaborative formulation:

• working together

• developing trust

• understanding how Cynthia makes sense of her experience

• coming up with a working hypothesis

Treatment plan

Immediate goals of therapy

Dr Melissa Connell

• Reduce anxiety and distress

• Build coping skills

• Explore possible unprocessed grief associated with loss of father

• Improve mood

• Increase activities (e.g. painting, seeing friends, going out)

• Recovery orientation

Working with voices and delusions

Dr Melissa Connell

Psychological approaches:

• ACT for psychosis, Relating Therapy, CFT for psychosis, CBT for psychosis

Aims:

Voices

• Appraisal of voices, understanding beliefs, changing the relationship with voices

Delusions

• Distress reduction, engagement in meaningful activity, alternative explanations

Long term goals

Dr Melissa Connell

• Recovery focus – improving self-esteem, connecting with others, finding meaning, hopefulness,

self-determination, developing more adaptive resources for coping, community supports

• Understanding personal stress-vulnerability factors, relapse prevention

• Ongoing support for managing anxiety and voices

• Groups – e.g. Hearing Voices

• Explore unresolved trauma (assess traumatic memories, potential benefits of trauma-focused treatments such as

Eye Movement Desensitization and Reprocessing (EMDR)

Orientation phase of relationship / alliance building

Dr Richard Lakeman

• Getting to know each other and building a shared understanding

• Attempting to understand the world as Cynthia experiences it: curiosity, humility, respect, openness

• Empathic listening – particularly for the as yet untold story

• Assessment –? Maastricht Interview for Voice Hearers

• Normalising extra-ordinary experiences such as hearing voices, jumping to conclusions etc

• Explore and promote positive mental health – positive emotion, engagement, relationships, meaning,

and accomplishment + physical activity, nutrition, sleep

• Mobilise and / or extend supportive networks e.g. Hearing Voices Network.

Identification / working phase

Dr Richard Lakeman

• Cynthia begins to identify the nurse as a helping person

• Detailed developmental and trauma history

• Strengthening and mobilising resources

• Coaching around dealing with paranoia and intrusive thoughts e.g.

• Having a thought does not make it a fact (I thought…. But I really know that….)

• Having a strong feeling doesn’t mean that something will happen (I feel…. But I know that….).

Identification / working phase

Dr Richard Lakeman

• Assist with coping with voices:

• Intrusiveness / beliefs about voices

(omnificence and omnipotence)

• Rationalising medication and clarifying

the expected effects of medication

• Arriving at a working problem formulation

(a shared way of making sense of the problem)

• Goal setting and negotiating a way forward.

Source: https://testandcalc.com/voices/

Exploitation / working / ending

Dr Richard Lakeman

• Cynthia begins to exploit the helping

relationship to clarify needs and have these

met

• Therapy as negotiated and as suggested by

the formulation

• Advanced empathy

• Recovery planning / relapse prevention –

Who does what?

• Referrals as needed.

Lakeman R. Adapting psychotherapy to psychosis. Australian e-Journal for the Advancement of Mental Health. 2006;5(1):22-33.

Q&A

Dr Cathy Andronis

General Practitioner

Russell

Lived Experience

Advocate

Dr Richard Lakeman

Mental Health Nurse

Facilitator:

Julianne Whyte

Mental Health

Social Worker

Dr Melissa Connell

Psychologist

Before you go

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Upcoming webinars:

Suicide Prevention and Safety Planning, in partnership with the DVA

a special one-off event with American researcher Professor Barbara Stanley

Collaborating to recognise and address conduct disorder

Register now at www.mhpn.org.au

Thursday 13 Nov

Tuesday3 Dec

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www.mhpn.org.au/find-network

Thank you and good evening