The Effect of an Educating versus Normalizing Approach on Treatment Motivation in Patients Presenting with Delusions: An Experimental Investigation with Analogue Patients

Assessing one's sense of normalcy: psychometric properties of the subjective normalcy inventory

OBJECTIVES

Individuals facing a personal challenge, such as age-related memory changes, may feel that their experiences are abnormal or pathological. Previous qualitative research on a group intervention that focuses on memory changes in older adulthood revealed that one of the greatest benefits derived by participants was the realization that their experience with memory changes was normal. In order to quantify this experience, we developed and validated a new measure, the 26-item Subjective Normalcy Inventory (SNI).

METHOD

Reliability and validity were assessed with a sample of 167 community-dwelling adults between the ages of 55 and 90. Questionnaire responsiveness was assessed with an additional sample of 29 older adults who completed a 5-session memory intervention program known to cultivate normalization.

RESULTS

The SNI exhibited a two-factor structure, excellent test-retest reliability, ICC = .79, excellent internal consistency, Cronbach's α = .91, and good convergent, |rs| = .46-.58, and discriminant, rs = .02-.06, validity. The measure was also responsive to change, as participants who completed the memory intervention program reported a greater sense of normalcy relative to nonintervention controls, η²_p = 0.17.

CONCLUSION

The SNI has the potential to provide novel and useful outcome information for interventions designed to improve one's sense of normalcy and may be applied in both clinical and research settings. The SNI can also be modified, validated, and used to assess subjective normalcy with respect to other personal challenges outside of memory and attention changes.

Metacognitive Training Online

Abstract. Psychological interventions such as cognitive-behavioral therapy and metacognitive training (MCT) have proven to be effective treatments for schizophrenia, but only a small number of patients actually gain access to them. Internet-based interventions are effective, but hardly explored for schizophrenia. This pilot study created an Online-MCT to investigate the feasibility, efficacy, and possible negative effects of the program. Fifteen patients participated in this uncontrolled study. During the 6-week intervention phase, two-thirds of participants completed the whole program. Only 6.1 % of all possible negative effects were strongly agreed to. Symptom severity did not change significantly, but 80 % of participants were (very) satisfied with the program, suggesting that internet-based interventions could help reduce the gap in psychological treatments of schizophrenia.

The impact of negative treatment experiences on persistent refusal of antipsychotics

AIMS

We investigate reasons for persistent medication refusal in schizophrenia spectrum disorders and test whether factors that speak for a rational decision, such as negative experiences with medication or low symptom distress predict medication refusal, even after taking differences in insight into account.

METHOD

We included 45 participants with schizophrenia spectrum disorders, of which 20 had refused antipsychotic medication for at least three months and assessed reasons for taking or not taking medication, labeling condition as mental disorder ("insight"), experiences with the previous treatments, symptoms and symptom distress, positive and negative consequences and experiences of psychosis, causal beliefs, therapeutic relationships with previous clinicians and attitudes towards medication.

RESULTS

Groups did not differ in symptom severity but medication refusers reported significantly less insight, less satisfaction with their most-recent psychiatrist and with previous medication, and more negative beliefs about harmful effects of medication. They also felt less informed about medication. After controlling for insight, the perceived helpfulness of the previous treating psychiatrist (OR=0.30, z=5.58, p=0.018) and of previous medication (OR=0.27, z=6.87, p=0.009) and feeling insufficiently informed about medication (OR=0.53, z=3. 85, p=0.050) significantly predicted medication discontinuation.

CONCLUSIONS

Building rapport with patients with a different view of the nature of their condition and encouraging informed decisions on medication are likely to improve medication adherence. However, the findings also suggest that refusing medication after a phase of initial adherence is also the consequence of negative experiences with medication and could result from weighing the pros against the cons.

What is the minimal dose of cognitive behavior therapy for psychosis? An approximation using repeated assessments over 45 sessions

BACKGROUND

The general efficacy of cognitive behavior therapy for psychosis (CBTp) is well established. Although guidelines recommend that CBTp should be offered over a minimum of 16 sessions, the minimal number of sessions required to achieve significant changes in psychopathology has not been systematically investigated. Empirically informed knowledge of the minimal and optimal dose of CBTp is relevant in terms of dissemination and cost-effectiveness.

METHODS

We approached the question of what constitutes an appropriate dose by investigating the dose (duration of CBTp)×response (symptomatic improvement) relationship for positive symptoms, negative symptoms and depression. Patients with psychotic disorders (n=58) were assessed over the course of 45 sessions of CBTp in a clinical practice setting. At baseline and after session 5, 15, 25, and 45, general psychopathology, psychotic symptoms, symptom distress and coping were assessed with self-report questionnaires. Additionally, individually defined target symptoms and coping were assessed after each session.

RESULTS

Significant symptom improvement and reduction of symptom distress took place by session 15, and stayed fairly stable thereafter. The frequency of positive and negative symptoms reached a minimum by session 25.

CONCLUSIONS

Our findings support recommendations to provide CBTp over a minimum of 16 sessions and indicate that these recommendations are generalizable to clinical practice settings. However, the findings also imply that 25 sessions are the more appropriate dose. This study contributes to an empirically informed discussion on the minimal and optimal dose of CBTp. It also provides a basis for planning randomized trials comparing briefer and longer versions of CBTp.

Motive-oriented therapeutic relationship building for patients diagnosed with schizophrenia

Treatment options for patients with schizophrenia demand further improvement. One way to achieve this improvement is the translation of findings from basic research into new specific interventions. Beyond that, addressing the therapy relationship has the potential to enhance both pharmacological and non-pharmacological treatments. This paper introduces motive-oriented therapeutic relationship (MOTR) building for schizophrenia. MOTR enables therapists to proactively adapt to their patient’s needs and to prevent problematic behaviors. For example, a patient might consider medication as helpful in principle, but the rejection of medication might be one of his few remaining means for his acceptable motive to stay autonomous despite hospitalization. A therapist who is motive-oriented proactively offers many degrees of freedom to this patient in order to satisfy his need for autonomy and to weaken the motivational basis for not taking medication. MOTR makes use of findings from basic and psychotherapy research and is generic in this respect, but at the same time guides therapeutic action precisely and flexibly in a patient oriented way.

Frequency and correlates of maladaptive responses to paranoid thoughts in patients with psychosis compared to a population sample

INTRODUCTION

The aims of this study were to identify whether responses to paranoid thoughts distinguish patients with psychotic disorders from people in the population who have paranoid thoughts occasionally and to identify factors that are associated with and might explain the different ways of responding.

METHODS

Paranoid thoughts were assessed in patients diagnosed with a psychotic disorder (n = 32) and a population control sample (n = 34) with the Paranoia Checklist. Responses to paranoid thoughts were assessed with the Reactions to Paranoid Thoughts Scale (RePT) and social support, self-efficacy and cognitive insight were assessed as potential correlates of the responses to paranoid thoughts.

RESULTS

The patients showed significantly more depressed, physical and devaluating responses to paranoid thoughts and employed less normalising responses than the controls. The differences in normalising responses were explained by perceived social integration, whereas the differences in depressive responses were explained by the overall levels of depression and partly explained by externality and social integration.

CONCLUSIONS

Maladaptive responses to paranoid thoughts could be relevant to the pathogenesis and maintenance of persecutory delusions. Interventions aimed at reducing paranoia could benefit from targeting dysfunctional responses to paranoid thoughts and by placing a stronger emphasis on treating depression and improving social integration.