Evidence-Based.txt

First-episode psychosis (FEP) usually refers to the initial psychotic episode of a primary psychotic disorder, which often results in fear, confusion, and significant disruption in the individual’s life and that of the family. Over the past decade, specialized FEP programs, which combine antipsychotic treatment with psychosocial treatments, have become more widespread in the United States. Individual, group, and family psychotherapy components of comprehensive programs are critical in helping clients and families understand and process the experience of psychosis and learn strategies to promote recovery and well-being.
Coordinated specialty care (CSC) programs (referred to as early intervention services [EISs] in Europe and Australia) provide team-based, comprehensive, evidence-based care, education, and support to engage clients and their families early in the course of illness.1 The goals of these programs are to reduce the duration of
untreated psychosis (DUP; ie, the period between onset of symptoms and initiation of antipsychotic medication treatment), prevent further disability, and promote recovery and well-being.
There are differences in the eligibility criteria across programs,2 but typically CSC programs treat individuals between 15 and 40 years of age (although the United Kingdom has begun offering FEP services to anyone regardless of age)3 who are within the first few years of the onset of their psychosis. CSC programs are intended for individuals with primary psychosis and are not meant for individuals whose psychotic symptoms are judged to be secondary to substance use (eg, substance-induced psychosis), a mood disorder (eg, bipolar disorder, major depression), a developmental disability (eg, autism), or posttraumatic stress disorder. The most common diagnoses of persons treated in CSC programs are schizophreniform disorder, schizophrenia, and schizoaffective disorder.
RESEARCH SUPPORT
CSC programs have been shown to yield better outcomes than treatment as usual, including fewer symptoms, more school/work participation, less treatment dropout, and reduced use of inpatient services.4 Studies have consistently highlighted both the importance of well-resourced EISs,5,6 and of shortening DUP to improve outcomes in persons with FEP.7-9
United States
Recovery After an Initial Schizophrenia Episode (RAISE) was a large-scale research initiative, funded by the National Institute of Mental Health (NIMH), which involved 2 studies in the United States, the RAISE-ETP trial7,10 and the RAISE Connection Program Implementation and Evaluation study.11 The RAISE-ETP trial enrolled 404 participants in a cluster randomized controlled trial involving 34 community mental health centers in 21 states to deliver 24 months of the NAVIGATE program (a CSC program) or usual care. At 2-year follow-up, participants who received NAVIGATE remained engaged in treatment for a longer period, and demonstrated greater reductions in symptoms, greater improvement in quality of life, better interpersonal relationships, and more involvement in work/school. Outcomes were moderated by DUP, such that those with a shorter DUP (<74 weeks) benefited more from NAVIGATE than those with longer DUP (>74 weeks).12 Client and clinician family therapy manuals (and other resources from the NAVIGATE program) are available online: https:// navigateconsultants.org/manuals/.
The RAISE Connection Program Implementation and Evaluation study enrolled 65 persons with FEP to receive a CSC program and demonstrated the feasibility of delivering CSC, including high rates of engagement.11 Another study, the Specialized Treatment Early in Psychosis (STEP) in Connecticut,13 demonstrated that those engaged in CSC, compared with usual or community care, were less likely to be hospitalized (40.0% in CSC compared with 63.1% in usual care), had significantly fewer inpatient bed days, and showed improvements in vocational engagement.14
Across the World
In the United Kingdom, the standard of care requires individuals with FEP be engaged with EISs within 2 weeks of the initial referral, or offered an assessment if considered to have an “At-Risk Mental State,” shown to reduce DUP.15 EISs in the United Kingdom have been linked to reduced hospital admission rates, lower relapse rates
and symptom severity, and overall improved access to treatment.16 Superior effects of CSC programs also have been demonstrated in other countries in Europe, Canada, Australia, and Hong Kong.17-20
COMPONENTS AND DELIVERY OF COORDINATED SPECIALTY CARE
CSC is composed of pharmacologic management (once a month), individual psychotherapy (weekly),21 family psychoeducation,22 supported employment and education (SEE; weekly),23,24 case management (weekly), and when available, peer support services.25 Although there is some variability, CSC programs generally offer time-limited care over a period of 2 to 3 years. However, immediately stopping care at 2 years may be detrimental to an individual’s recovery, particularly if the patient has built a good therapeutic relationship.26 If treatment is required beyond those 2 years, the individual may step down to a lower level of care, with a transition into regular adult services.27
CSC involves a multidisciplinary team ,and each team member has a distinct role. For example, the team psychiatrist/prescriber uses a shared decision-making approach in collaboration with the individual with FEP to identify the most effective and tolerable medication(s) at the lowest possible dose.28 Using an adapted Individual Placement and Support model of supported employment for serious mental illness,29 the SEE specialist works closely with the client to identify goals related to returning to work and school and provides support across all phases of the employment or education process. Case management focuses on providing resources for basic needs (eg, transportation, insurance) ideally using assertive outreach to promote engagement, respond to crises, or provide services when necessary.30 Although the peer support role is newer and therefore less well-defined, individuals with lived experience of mental health illness provide valuable support for individuals with FEP,31 for example, by increasing hopeful attitudes about recovery through sharing their own recovery story, providing support, and facilitating the client’s personal goals around community engagement (eg, exercise, going to coffee shops, or becoming more involved in extracurricular school activities). Team meetings are also key to optimal sequencing and coordination of treatment components based on the client’s goals. The team typically meets weekly for assessment and treatment planning and communicates closely with outside organizations to provide appropriate community support.
The following section elaborates on the content, goals, and strategies used in individual, group, and family therapies for persons with FEP.
INDIVIDUAL, GROUP, AND FAMILY THERAPIES
The overarching objectives of group, individual, and family therapies in CSC are to 1. Help the client and family understand and cope with the experience of psychosis 2. Promote symptomatic and functional recovery and improve quality of life 3. Support the pursuit of personally meaningful goals of the client32
A positive alliance not only helps to engage clients and families in therapy but is also related to improved symptoms and functioning in persons with FEP.33-36 As such, therapies delivered as part of CSC share several common elements in terms of their primary objectives and focus on promoting engagement and a strong alliance. Psychoeducation about psychosis and its course serves as the backbone for many of these therapies to empower clients and their families to make informed decisions both about treatment and other important aspects of clients’ lives (eg, returning to school/work). Further, given that engagement in treatment can be challenging, it is critical for therapists to prioritize developing and maintaining a strong therapeutic
alliance with clients and families, which involves agreement on goalsand tasks of therapy, as well as the presence of a supportive bond.37 The use of reflective statements as well as an emphasis on collaboration, shared decision-making, and autonomy can foster a supportive bond as well as improved therapy engagement.38
Individual Therapies
Cognitive behavioral therapy for psychosis (CBT-p) aims to help clients understand and cope with symptoms, prevent relapse, and identify and work toward meaningful goals through an improved understanding of how thoughts and beliefs shape emotional reactions and behaviors in response to events.39-41 CBT-p has garnered substantial support for its use with persons with established schizophrenia and FEP.16,42,43 Although CBT-p is often delivered as an individual therapy, there is evidence that it also can be effectively delivered as a group psychotherapy.44,45 Therapists delivering CBT-p often use Socratic questioning techniques to explore clients’ understanding of their experiences and to help them identify stressors and vulnerabilities, and the stress-vulnerability model46 is often used as a framework to discuss precipitants of the initial psychotic episode as well as to identify protective factors to prevent relapse. This therapy includes both psychoeducation about psychosis and collaborative exercises aimed to help clients generate and test out alternative methods for coping with symptoms and appraising current past and present experiences, including the experience of psychosis. CBT-p is typically delivered as 16 weekly sessions over 6 months.21,47 Persons with FEP are encouraged to complete homework between sessions to promote continued understanding and practice of CBT-p exercises.43
Individual Resiliency Training (IRT) served as the individual therapy component of NAVIGATE in the RAISE-ETP study and has been identified as a valuable intervention for persons with FEP.7,32,48 IRT is rooted in CBT-p, training in illness selfmanagement, and psychiatric rehabilitation. IRT is a manual-based therapy that emphasizes the enhancement of resiliency and strengths to support individuals’ pursuit of meaningful goals and to improve their illness management, social functioning, quality of life, and well-being. IRT draws from the structure of the Illness Management and Recovery program49 and earlier psychotherapeutic approaches for FEP emphasizing positive psychology.50 IRT contains 7 “standard” modules that are considered foundational for all persons with FEP in CSC as they help to frame the therapy, support the person in setting goals and preventing relapse, provide psychoeducation about psychosis, offer a structure to process the episode of psychosis, and promote resiliency. The standard modules cover the following:
1.	Orientation
2.	Assessment and goal-setting
3.	Education about psychosis
4.	Relapse prevention planning
5.	Processing the episode
6.	Developing resiliency: part one
7.	Building a bridge to your goals
IRT also contains 7 “individualized” modules that cover the following:
1.	Dealing with negative feelings
2.	Coping with symptoms
3.	Substance use
4.	Having fun and developing good relationships
5.	Making choices about smoking
6.	Nutrition and exercise
7.	Developing resiliency: part two
The decision to offer the content of the individualized modules is made collaboratively between the therapist and client based on the client’s personal goals.48 IRT is typically delivered on a weekly or biweekly basis for as long as needed (eg, delivered for 2 years in the RAISE-ETP trial7,32,48).
Group Therapies
Group-based therapies that target social cognition and social skills are effective in promoting functioning51,52 and negative symptoms53 among those with established schizophrenia. A few studies have examined their use in FEP populations,44,54,55 and these studies demonstrate considerable promise given the social cognitive difficulties that persons with FEP experience.56 Social Skills Training (SST57) is an evidence-based intervention that focuses on helping individuals learn and practice skills involved in social interactions (eg, making requests, expressing positive feelings). SST groups often include a discussion of the rationale for a skill, specific steps of the skill, role-play exercises, feedback from the group, and homework assignments. This intervention has been shown to help individuals learn and practice social skills within the group setting and, subsequently, use them effectively in the community. Number of sessions per week and total weeks depend on the needs of the clients and the setting in which it is delivered (eg, mean number of weeks = 19.3 with a range of 2-104 weeks reported in one study).52
Cognitive enhancement therapy (CET58) has shown benefits in schizophrenia and in early psychosis. CET is composed of computer training (focused on attention, memory, and problem-solving) group therapy (focused on perspective-taking, managing emotions, reading nonverbal cues, and interpreting social situations).59 CET typically consists of 60 hours of computer training and 45 weekly group sessions. This integrated intervention has been shown to improve social cognition and neurocognition in those with established schizophrenia60 and in those with FEP.61
Stand-alone social cognition training interventions aim to improve individuals’ capacity to understand, interpret, and use social information effectively, often targeting one or more of the primary domains of social cognition: theory of mind, emotion perception, social perception, and attributional style.62 For example, Social Cognition Interaction Training (SCIT), has been examined extensively in established schizophrenia and has been piloted in a sample of persons with FEP.63 SCIT is delivered as a 20-session to 24-session group psychotherapy typically delivered weekly64 that includes 3 phases: emotion training (eg, identifying emotions from photos of faces, relationship between emotions and thoughts), figuring out situations (eg, distinguishing between facts and guesses in social situations), and integration (discussion of how information can be applied to salient situations). Individuals learn effective social cognitive strategies, practice them within the groups, and ultimately use them in everyday interactions.
Family Therapies
Historically, family interventions have been underutilized in the treatment of individuals with schizophrenia,65 despite their clear benefit in reducing relapse and rehospitalization.66-68 Over recent years, however, family interventions have occupied a more central role in the treatment of FEP.12 Family intervention, as part of CSC, typically includes education, validation of the impact of psychosis on the family, communication, problem-solving, and goal-setting skills training.
Family education about psychosis and its optimal management serves a number of purposes:
1.	Developing a shared language for the treatment team, individual, and the family to talk about psychosis and associated symptoms
2.	Providing information so that individuals with psychosis and their families can make informed choices about illness management
3.	Orienting the family to how they can support the management of their relative’s illness and pursuit of personal goals
Educational topics include information about psychosis and associated symptoms, the stress-vulnerability model of psychosis, diagnosis and prognosis, the role of the family in treatment, early warning signs monitoring, and relapse-prevention planning. Family education provides the opportunity for family members to observe how the clinician talks to the individual with psychosis about symptoms, diagnosis, treatment, and recovery.
Families are often put under tremendous stress due to the disruptions in the family system that result from an episode of psychosis. A key underlying aspect of family interventions is the validation of this stress for the entire family system. Before the onset of the psychosis, the young adult may have been living independently, such that the onset of an illness represents a shifting of roles and worry for the entire family system. Communication, problem-solving, and goal-setting skillstraining can be important for families during this period of adjustment and heightened stress. Communication skills are aimed at reducing stressful interaction styles characterized by strong displays of negative affect or ambiguous messages and emphasize the use of direct “I statements,” reference to specific behaviors, and specific feeling statements taught using the principles skills training (eg, modeling, role playing). Common targets for communication include medication, symptoms, and disclosure of information about the illness with the immediate, as well as the extended, family. In addition, it may be important for family members to reestablish how they will make requests of one another, which dovetails with the question of reasonable expectations of the individual with psychosis during the immediate period following illness onset and beyond.
Fostering problem-solving and goal-setting skills in the family serves the dual purpose of minimizing strife and facilitating recovery through each family member’s identification of meaningful goals. Early in treatment, families often work toward the goal of increasing shared pleasant activities, which can increase family connection, shift the focus from illness to enjoyment and fun, and help remediate negative symptoms and demoralization that are commonly associated with the experience of psychosis. Later in treatment, families often take on more challenging goals, such as assisting the young person in returning to school or work, living independently, or traveling for educational or leisure purposes.
Multifamily group (MFG) interventions typically include 5 to 7 families who meet with 2 clinicians on a biweekly basis,69 following “joining” sessions in which each family meets individually with the clinician to form a relationship and provide information about their family’s specific needs. Each MFG session lasts approximately 90 minutes and the content of the sessions map onto 4 treatment stages corresponding to the phases of an episode of psychosis: (1) engagement between client and their family, (2) education about the psychotic disorder, (3) development of strategies, such as stress reduction, to cope with the challenges of psychosis recovery, and (4) social and vocational rehabilitation.69 Elements of MFG considered to be particularly effective include access to a social network, reduction in perception of stigmatization, availability of mutual aid, and the opportunity to hear similar experiences and
solutions.69 Although there can be some initial challenges with establishing a critical mass of families willing to attend a group, MFG is cost-effective70 and has been demonstrated to increase perception of ability to cope with a relative’s psychosis,71 and reduce FEP program dropout rates.72
CLINICAL CHALLENGES
Individuals with FEP vary tremendously from one another in terms of the severity of positive symptoms, negative symptoms, and cognitive and social functioning. The most significant challenges in therapy with individuals with FEP arise from the need to adapt the treatment to each individual’s specific symptom presentation and understanding of his or her problems. Problematic substance use73 and history of trauma or posttraumatic stress disorder74 also add complexity to the treatment of some individuals. Furthermore, significant stressors beyond coping with FEP (eg, limited income, transportation barriers, homelessness) can interfere with the feasibility of delivering treatment and, thus, should be considered when trying to engage and maintain persons in therapy. In these instances, mobile teams and/or case management supports (eg, transportation paid for by health insurance or access to disability pay-ments75) are essential ingredients to involve the individual and family in care and reduce strain on poorer families.
Negative symptoms, cognitive deficits, and impaired social and occupational functioning tend to co-occur in primary psychotic disorders and are defining features of FEP. Clinicians may struggle to engage individuals with negative symptoms and families may blame these individuals for being “lazy” or “unmotivated,” which can amplify familial stress and impede recovery. Education about negative symptoms, spending more time getting to know the individual (eg, befriending techniques76,77), and slowing down the pace of therapy as well as breaking goals into small steps can be useful. An important part of the educational process involves dispelling the myth that negative symptoms indicate a lack of distress, because in fact, individuals with negative symptoms are often bothered by these symptoms and this is related to poor quality of life.78 Therefore, recognizing and labeling this distress can serve as a rationale to build coping skills for these symptoms. Another important discovery has been the identification of common dysfunctional beliefs expressed by individuals with negative symptoms,79,80 such as beliefs about self-efficacy (eg, “I don’t have enough energy or I don’t have anything to say”) and anticipatory pleasure (eg, “I won’t have a good time”), which are thought to impair effortful responding and can be addressed through cognitive restructuring and behavioral experiments.81,82 Further, given the variability in cognitive functioning among persons with FEP (eg, due to age, effects of medication/ electroconvulsive therapy, symptoms), psychosocial interventions should be appropriately tailored to the cognitive capacity of each individual.
Another challenge when working with persons with FEP and their families is sensitively and effectively addressing the role of trauma in therapy. Many persons with FEP have had traumatic experiences in their lives,83 which may have been associated with the experience of psychosis and psychiatric treatment (eg, involuntary hospitalization, coercive treatment, use of restraints, and/or police involvement).84 IRT includes a module called “processing the episode,” which aims to help individuals integrate, process and understand the trauma of experiencing psychosis, and interventions designed to facilitate cognitive processing of traumatic experience in FEP have shown positive outcomes.85
Cultural and religious factors can also impact the willingness of clients and families to engage in treatment. For example, individuals of some cultural and religious
backgrounds may not believe that psychological or psychiatric medication approaches to treatment are appropriate and may seek out alternative options (eg, shaman, exorcism, religious practices). Therapists should try to work within the cultural context of the given client and family to best support the recovery of the person with FEP. Therapists should use a curious attitude about these alternative approaches and better understand how they fit within the cultural context of the family and, importantly, assess any potential risk for the person. However, people may also be open to alternative explanations of their experience, especially when they are less distressing or more helpful. Therapists may also offer an “open door” policy so that individuals and families know that they are welcome to reconnect in the future.
SUMMARY
CSC programs provide team-based, comprehensive, evidence-based care, education, and support across 2 to 3 years to individuals experiencing their first episode of psychosis and their families. A collaborative clinical approach within CSCs are important. Individual, group, and family therapies represent critical aspects of CSC as they are aimed at helping individuals with FEP and their families navigate the distressing experience of psychosis and to promote recovery and well-being. Several individual (eg, CBT-p, IRT), group (eg, SST, SCIT, CET), and family (eg, family psychoeducation) therapies have demonstrated benefits for this population and are guided by the individual’s goals and long-term vision of recovery. However, there are many clinical challenges that often accompany FEP therapy delivery that warrant significant attention. Therapists should be aware of these challenges and develop strategies to engage and maintain clients and their families in therapy. It is through awareness of challenges, prioritization of the therapeutic alliance, and effective delivery of evidence-based therapies that therapists can help clients and their families work toward recovery.