Peter Stastny,* MD, writes about an upcoming conference (Nov 23): "Alternative responses to first psychotic breaks: Rethinking psychiatric crisis."
After several years, there is a renewed focus on treatment for first psychotic episodes. An emphasis on early intervention and prevention of psychosis, with the goal of shortening the "duration of untreated psychosis" has obscured the view on the actual services that are being offered to individuals in the midst of a first episode. Recently, the National Institute of Mental Health challenged the psychiatric field to develop a new, state-of-the-art intervention for an "initial schizophrenic episode" (RAISE), realizing that the outcome of conventional treatment leaves a lot to be desired.
Counter to common belief, a first psychotic episode may actually not have disastrous consequences. It may not herald a course characterized by multiple relapses, re-hospitalizations and a decline in functioning, social and economic standing, relationships and general well-being. Instead, a first breakdown may constitute an opportunity for early recovery and result in a positive realignment of psychological and social constellations, provided that interventions are tailored to the actual needs of the individual, respond to a crisis that has frequently taken hold of the person's entire social support system, and ensure that no additional harm is inflicted at a time when a person is already quite vulnerable.
Interventions that fit this bill have been around for many years. Even going back to the days of moral treatment in the 19th century, one can find many instances of early recovery when people responded to the kind guidance and structure available in the best asylums. Scandinavian psychiatrists have long been at work to optimize interventions for first psychotic episodes, integrating family treatment, individual psychotherapy, optimal and targeted use of medication into a flexible package they termed "need-adapted treatment." Several studies using variations of this approach have shown dramatically positive results, with little use of inpatient services, and much lower medication dosages than usual.
In this country, the Soteria study conducted by Loren Mosher and Alma Menn showed short-term benefits equal to acute hospitalization with significantly less use of antipsychotic medication, benefits that were sustained for at least two years. Countries that have managed to significantly reduce their reliance on inpatient services, such as the UK, Scandinavia and Italy, have been more open to embrace community-based innovations that are flexible, continuous, and supportive of individual resilience and social ties. But mental health consumers in the United States have benefited the least from such promising programs, due to the persistence of hospital-based services, a lack of suitable funding mechanisms, and little awareness about the safety and successes of these interventions.
The voices of consumers and family members who have been through such experiences need to be heard as we are searching for better solutions. In fact, many former patients have become supporters of their peers in going through crises, and have developed approaches that are particularly responsive to the individuals' needs. Trauma-informed interventions have been championed by consumer/survivors and mental health professionals alike, subscribing to the view that psychosis is often a consequence of traumatization, and that additional trauma is often associated with being thrust for the fist time into the conventional services that are generally available. Family members too have often expressed their disappointment with the way their loved ones had been treated at the onset, naturally most often in hindsight, when it might already be too late to turn things around.
Rather than wait for the results of the RAISE project, which are not likely to become available for several years, the time is now to look at some of the tried and true, but non-traditional options. Questions such as when, how and how much medication is best applied; whether hospitalization is always necessary, or can frequently and safely be replaced by homelike residential settings, or even by services provided in the persons home, thus preserving the integrity of the family and the support system. Is the danger of psychosis to the person experiencing it and the social environment exaggerated in the service of minimizing risk and liability for the helping professions? Can we find viable ways of engaging the suffering person's own agency - her own reflective powers - as part of passage through the crisis?
These questions and more will be addressed at a one-day conference on November 23, 2009, at the NYU Kimmel Center, co-sponsored by the International Network towards Alternatives and Recovery, (INTAR) and the Center to Study Recovery in Social Contexts. INTAR is a knowledge- and learning-community composed of advocates and practitioners from around the world who espouse alternative ways of supporting individuals in serious mental health crisis. The Center is a participatory research program dedicated to exploring the meaning and determinants of social recovery for persons diagnosed with severe mental illness. The conference will feature 25 speakers and workshop leaders who have spearheaded innovative projects to intervene in first break situations and other major crises.
*Peter Stastny is a psychiatrist who has been involved in numerous aspects of community psychiatry for nearly 30 years. He was on the faculty Albert Einstein College of Medicine and is co-author (with Darby Penney) of The Lives they Left Behind - Suitcases from a State Hospital Attic.