1. Engagement, Adherence, Transition to Community & Course Wrap-Up Demian Rose, MD Rachel Loewy, PhD Linda May, PhD, MFT

2. Engagement Challenges  Reluctance to attend therapy  No prior, or unsuccessful prior treatment  Anticipate consumers possible concerns  Solicit consumers own description of concerns, prior experiences  Address concerns, normalize when appropriate  Educate regarding cognitive behavioral approach  Refuses medication  Educate regarding medications, symptoms could assist  Continue to work and engage with consumer separate from medication decision  Educate regarding risks of making own medication changes, encourage honesty, provide acceptance of collaboration

3.  Social isolation  Typically social decline and/or withdrawal precede first episode  Isolation is a prime aspect of decline in function (along with genetic risk and attenuated psychotic symptoms)  Go slow in development of therapeutic alliance, exploration of symptoms  Display acceptance, empathy and tailor communication to consumers problems with thought processing, and affect  Impact of symptoms  Clinician maintains awareness of potential interference of consumer symptoms – as unusual thought content, overvalued beliefs, ideas of reference, suspiciousness, perceptual abnormalities – on communication and engagement  Regular feedback to check with consumer regarding her/his understanding – clinician recalibrate based on feedback

4.  Fear of “going crazy”  Experience with family member, and/or exposure to cultural myths, explanations may concern consumer  Anticipate and explore consumers impressions and provide education (Explore possible worries even if not offered spontaneously – normalize)  Educate regarding improved treatment options, the possible positive outcomes that are not as common a knowledge  Stigma   Explore consumers myths, impressions, experiences regarding mental illness as presented by peers, family, media   Relate treatment of this biologically based disorder to adjustment to other chronic disorders as diabetes   Re-explore throughout treatment the consumers gradual adjustment to a chronic illness, including grief/loss of aspects of prior self image

5. Engagement techniques  Go Slow  Develop and test “hypotheses”  Focus on the client’s identified problems  Include families, but client has the final say on most decisions  Use the team

6. Adherence techniques  All decisions are collaborative  Remain open to multiple treatment options  If clients refuse treatment, keep the dialogue going  Ask permission to follow-up for outcomes

7. Take Home Points  Neuroscience  Medication  Psychotherapy

8. Neuroscience  Psychosis describes 4 clinically related phenomena, all of which can be conceptualized as errors in information processing at multiple levels of analysis

9. Neuroscience  Causes of psychosis are multi-factorial and the prognosis of psychosis is highly variable, depending on type, risk factors, treatment and psychosocial environment

10. Neuroscience  Psychosis does not represent one specific type of brain process that is fundamentally different from “normal” (neurotic, etc.) process

11. Medication  Persistent psychotic symptoms that resist reality testing and impair function should almost always be treated with anti- psychotic medications

12. Medication  “Prodromal” or ultra-high risk symptoms are not specific enough to be treated with anti-psychotic medication in many cases (cost/benefit analysis)

13. Medication  The longer psychosis goes untreated by medication, the more treatment-resistant and severe it tends to become

14. Psychotherapy  It is an outdated myth that psychosis is resistant to psychotherapeutic intervention  CBT for psychosis is evidence-based, i.e. it works!

15. Psychotherapy  Normalize and don’t panic!  Focus on alternative explanations, attentional biases and safety behaviors as points of possible intervention

16. Coming soon….  Bi-monthly consultation/supervision group