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Rehab Rounds: Psychosocial Rehabilitation Early After the Onset of Psychosis
David Whitehorn, David; Lazier, Lorraine; Kopala, Lili
Psychiatric Services, 1998, Volume 49 (Issue 9), Seite 1135-1147, Washington D. C.: Eigenverlag, ISSN: 1075-2730 (Print); 1557-9700 (Online)
Introduction by the column editors: Intervention at the onset of psychotic disorders is a highly attractive theoretical notion because its goal is secondary prevention, that is, the prevention of chronic illness. As such, early intervention has practical relevance as well, given the enormous social and economic impact of chronic mental illnesses.
It is all the more curious, then, that few mental health programs have been designed to identify and treat individuals who are in the throes of their first psychotic episode. One such program, developed by Lili Kopala, David Whitehorn, and their colleagues in Nova Scotia, incorporates many of the basic principles of psychiatric rehabilitation such as providing a supportive environment, identifying clients' goals and aspirations, involving families, and emphasizing social and academic or vocational reintegration into community life. It also includes several aspects unique to the experiences of young people who have experienced a first psychotic episode, such as a group designed to help members overcome obstacles encountered when returning to school, work, and social settings. The following description of the program may remind us of the value of rapid early detection of a first psychotic episode followed by intensive and persistent intervention.
In our clinical work with young people in the early stages of recovery from psychotic illness, we have encountered many clients whose experiences are similar to those presented in the following vignette. Phillip, 22 years old, experienced psychotic symptoms for more than two years before his condition was recognized and effective medication treatment started. Three months later, his hallucinations were gone, and the apathy and lethargy that were so prominent were replaced with renewed energy and interest in the future. But for the past month his attendance at the psychosocial rehabilitation program in his community has been sporadic. 'Basically, the people there are older, and their expectations for themselves are much lower than mine,' he explained. 'I'm thinking about going back to school and getting together with some of my old friends.'
The young people who come to us have experienced varying periods of declining function, often a year or more, culminating in the recognition of a psychotic disorder and the initiation of treatment. Often there have been obstacles along their pathway to care. In some instances, as in Phillip's case, the emerging psychosis had been attributed to drug use, thus delaying and complicating effective treatment (1).
In the vast majority of cases, young people experience significant and rapid improvement in mental status and functioning once appropriate antipsychotic medication is initiated. Nonetheless, they have been sidetracked from their previous developmental path. Many have lost jobs, dropped out of school, and lost contact with their friends. They struggle with the news that they have a psychiatric disorder. Although they may question their own ability to return to their previous social, vocational, and educational activities, they consistently state their goal as 'leading a normal life.'
This paper describes an outpatient program begun in autumn 1996 in Nova Scotia to help people during the initial stages of recovery from a psychotic disorder. Sixty percent of the clients are 19 to 27 years old. Twenty percent are in their late twenties and early thirties, and 20 percent are younger than age 19.
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