1. Updates on psychotherapy: New findings from the RAISE study
David L. Penn, Ph.D
University of North Carolina at Chapel Hill
UNC OASIS Program
Julia Browne, M.A.

2. The RAISE study
The “Recovery After an Initial Schizophrenia Episode” initiative seeks to fundamentally alter the trajectory and prognosis of schizophrenia through coordinated and aggressive treatment in the earliest stages of illness.

3. Study Sites

4. RAISE-ETP Study Design with Cluster/Site Randomization
NAVIGATE
17 sites n = 223
COMMUNITY CARE
17 sites n = 181

5. Initial Findings
48.3% were obese or overweight
50.8% smoked
Correll et al., 2014, JAMA Psychiatry
Median duration of untreated psychosis is 74 weeks in community clinic settings
Addington et al., 2015, Psychiatric Services
Only 61% of FEP patients receive medications in line with PORT recommendations
Robinson et al., 2014, American Journal of Psychiatry

7. Nagendra et al (in press)
Black Americans, as compared to Caucasian Americans, were more likely to be:
Female
Homeless/transient
Publicly (rather than privately) insured
They were also more likely to have:
Disorganized symptoms
Lower quality of life
More impaired cognition
Lower education

8. Major Study Outcomes

10. Conclusions NAVIGATE > CC Improving quality of life
Increasing involvement in work and school
Reducing symptoms
Keeping clients engaged in treatment
Cost-effectiveness
DUP appears to be an important moderator of NAVIGATE effectiveness.

11. The role of therapy in the RAISE study

12. Participation in IRT in the RAISE ETP study
208 (93%) clients received IRT
Mean total IRT sessions = (SD=19.67)
Standard Sessions = 207 clients
Mean sessions = (SD = 12.59)
Individualized sessions = 119 clients
Mean sessions = (SD = 11.09)
Highest standard module participation
Orientation
Assessment and goal setting
Education about psychosis
Highest individualized module participation
Coping with symptoms
Dealing with negative feelings
Having fun and developing relationships

13. The importance of treatment engagement
Clients miss 20% of scheduled mental health appointments
30% of people with psychotic disorders disengage from treatment or completely dropout
Day et al., 2005; Higashi et al., 2013; Mitchell & Selms, 2007

14. Engagement in psychological treatment
What can help?
Therapeutic Alliance
Medication Adherence
Engagement in psychological treatment
Improved symptoms
Improved functioning
Horvath et al., 2011; Priebe et al., 2011

15. What makes a good alliance?
Therapeutic Alliance
Goals
Tasks
Bond
Bordin, 1979

16. Agreement on goals
Sample items from Working Alliance Inventory (WAI): 1) “The client and therapist are working on mutually agreed upon goals.” 2) “The client and therapist have different ideas about what the client's real problems are.”
Horvath, 1981

17. Agreement on tasks Sample items from Working Alliance Inventory (WAI):
“There is agreement that what the client and therapist are doing in therapy will help the client to accomplish the changes he/she wants.”
“The client is frustrated with what he/she is being asked to do in the therapy.”
Horvath, 1981

18. Bond Sample items from Working Alliance Inventory (WAI):
“The client and the therapist respect each other.”
“The client feels that the therapist appreciates him/her as a person.”
Horvath, 1981

19. What about in FEP? Psychological Well-being Mental Health Recovery
Therapeutic Alliance
Psychological Well-being
Mental Health Recovery
Quality of Life
Improved Symptoms
Browne, et al (in preparation - a)

20. Is the alliance affected by client factors?
Yes.
The following characteristics are associated with a better alliance in FEP:
Less severe negative symptoms
More insight into illness
Better social skills
More severe positive symptoms
Browne et al (in preparation - b)

21. Strategies to enhance the alliance and engage clients
Discuss goals and agree upon tasks to achieve those goals with patient
Have strong non-specific therapy skills
Support client autonomy to make decisions
Discuss client strengths in session

22. Autonomy Support
Empowering someone to make decisions based on his/her own values and preferences
Components of autonomy support:
Perspective taking
Providing a meaningful rationale for suggestion
Supporting an individual’s choices without attempting to exert control
Ryan & Deci, 2008; Ryan et al., 2011

23. Autonomy support examples
Items from the Autonomy Support Scale:
I feel that my clinician has given me choices and options.
My clinician conveys confidence in my ability to make changes.
My clinician encourages me to ask questions.
I feel understood by my clinician.
My clinician listens to how I would like to do things.
My clinician tries to understand how I see things before suggesting a new way to do things
Williams et al., 1998

24. Is it helpful? Medication Adherence Improved quality of life
Autonomy Support
Medication Adherence
Improved quality of life
Motivation
Health behavior change (e.g., smoking)
Ng et al., 2012; Williams et al., 2006

25. Autonomy support in RAISE
NAVIGATE was associated with improvement in Autonomy support over two years
Improvement in Autonomy support was associated with improvement in quality of life and decrease in total symptoms for both NAVIGATE and community care
Browne et al. (in press)

26. A strengths-based perspective

27. The importance of client strengths
Positive psychology perspective
Psychological well-being
Experiencing purpose and meaning in life
Individual Resiliency Training (IRT) incorporated a brief strengths test to be done in session

28. 24 Character Strengths Wisdom and Knowledge Creativity Curiosity
Open-mindedness
Love of learning
Wisdom
Courage
Honesty
Bravery
Perseverance
Zest
Humanity
Kindness
Capacity to love or be loved
Social intelligence

29. 24 Character Strengths Justice Fairness Leadership Teamwork Temperance
Forgiveness
Modesty
Caution
Self-control
Transcendence
Appreciation of beauty
Gratitude
Hope
Humor
Spirituality

30. Strengths in FEP
105 FEP clients who received IRT during RAISE ETP trial
Most Endorsed Strengths
Least Endorsed Strengths
1) Honesty, authenticity, and genuineness+
1) Social intelligence
2) Kindness and generosity+
2) Zest, enthusiasm, and energy
3) Fairness, equity, and justice+
3) Perspective (wisdom)
3) Gratitude+
4) Industry, diligence, and perseverance
3) Humor and playfulness
5) Bravery and valor -
5) Caution, prudence, discretion

31. Are certain strengths related to outcomes in FEP?
Humanity
Improved psychological well-being
AND
Improved positive symptoms
Kindness
Capacity to love or be loved
Browne et al (under review)

32. Are certain strengths related to outcomes in FEP?
Justice
Improved interpersonal relationships
Fairness
Leadership
Teamwork

33. Are certain strengths related to outcomes in FEP?
Transcendence
Appreciation of beauty
Gratitude
Hope
Humor
Spirituality
Improved total symptoms

34. Ways to use strengths to promote well-being
Goal is to encourage clients to use their existing strengths as opposed to develop new strengths
Practice using strengths outside of session
Use strength in a new way
Link strengths to goals of client
Use strengths to aid in problem solving difficult situations

35. Conclusions At the start of the study, clients with FEP
Have a long duration of untreated psychosis
May not be receiving adequate medical treatment for their mental illness
Have significant health risks
Have increased challenges if they are Black Americans
Key components of therapy in the study were:
Therapeutic alliance
Promoting autonomy support
Identifying client strengths