Inside an Early Psychosis Intervention Clinic

The second in a series of conversations with Krista Baker, creator and program supervisor of the Early Psychosis Intervention Clinic (EPIC) at Johns Hopkins Bayview Medical Center. Here she shares what it’s like inside an early psychosis intervention clinic, and how to best support someone through treatment.

P4SM: Tell us a bit about what entry into EPIC looks like.

Krista Baker: The vast majority of our outpatient referrals to EPIC come from inpatient units. There are approximately 20 hospitals in and around Baltimore, and we routinely go visit social workers on each of the hospital units to make sure they know our program exists and what the admission criteria is.

Once we’ve received a call that a patient is being discharged and needs services, we’re generally able to schedule them for an intake visit within five business days. We typically have them seen by a physician at the second visit, but we do have physicians here all the time, so if a person presents with side effects at intake, they can be seen by a physician that day. The first visit generally includes a therapist, myself, the program participant, and the family. Rarely do we have individuals come alone. We try to obtain documentation ahead of time giving us as thorough a history as possible so that we have an understanding of the person now sitting in front of us. The first appointment consists of gathering additional history, meeting the person and their family and explaining the services of the program.

Collecting history takes time and patience, but it’s a strategy for engagement with a population that tends to be difficult to engage. To spend the first appointment just talking about history is a challenge; there aren’t a lot of sixteen year olds who want to rehash what just happened to them. But engagement is crucial, so as a team we routinely focus on and talk about what works and what doesn’t.

P4SM: What happens after the initial visit?

Krista Baker: The second visit is generally with the physician, and then program participants have time to sit down with the therapist again. The second therapist meeting is meant to provide space for the patient to discuss what he or she wants to talk about. They may want to talk about why they’ve arrived at the clinic, what happened at the hospital, what their goals are, how they’re feeling about the process, or anything else that comes up for them personally. Through this conversation, we are able to start thinking about what our treatment plan is going to be.

Everything that we do at EPIC is patient and recovery-oriented. That means that we want people to get back to doing all of the things that they were doing prior to any of this happening. That may be returning to school, getting a job, or moving out of the house. Depending on what the goals are, we’re able to determine what the treatment will look like, what the services are going to be, and the overall plan.

If someone struggles with anxiety, we have case managers who will take them into the community and expose them to the experience of sitting in a busy waiting room, for example. Whatever it is that a person identifies as their problem is what we want to target. Let me give you an example. In 2010 we had a seventeen year old girl that was referred to us after her second inpatient hospitalization at a hospital here in Baltimore. They’d been back-to- back admissions, so she really hadn’t had time between the two to follow up with any outpatient treatment.

She was very sick; acutely psychotic, and delusional about a particular famous boy that she believed to be following her. She thought that everything she saw meant something specific for her. For instance, she was very focused on people’s hand gestures, because she thought that the movement and direction of the hands had an underlying meaning specifically for her. She couldn’t see beyond their hands; if the hands moved up, she believed that was something positive. If they moved down, or the palms faced down, she believed that was something negative. She’d been started on several different medications but was not seeing any benefit yet. This was very traumatic both for her and her family.

For about three and a half years, she came to EPIC routinely for individual therapy, where we utilized CBT (cognitive behavioral therapy) for psychosis. We held an eighteen-month multi-family group and she and her family joined. Over time, she slowly improved. She finished high school and went on to finish college.

She’s still taking medication, but she no longer needs to come regularly because she’s been symptom-free for a number of years. She’s doing amazingly well and is focused on carrying on her life in a happy and successful way.

Of course, there are people that unfortunately do not do as well. I think, ultimately the decisions people make and the resources available to them play a huge role in their ability to recover. Factors like substance use, sleep hygiene, and home life contribute to that overall long term prognosis.

P4SM: How do you counsel families and clinicians to work with someone who can’t see they need help?

Krista Baker: This does come up frequently in both youth and adults, as well. There is an amazing book called I Am Not Sick, I Don’t Need Help! How to Help Someone with Mental Illness Accept Treatment by Dr. Xavier Amador, that I highly recommend. It has great information for families and loved ones of people with schizophrenia who don’t believe they have an illness or want treatment for it. When we become argumentative with an individual who is struggling with a mental illness, all we’re doing is creating conflict and building a barrier between us and that person. Instead, you really have to be on the side of that person, and they have to know that you’re on their side.

This is an engagement strategy.

An example of this would be if you say something like, “I wear a size eight shoe,” and somebody tells you that you don’t wear a size eight shoe, you will likely start to give all of the reasons why you do, in fact, wear a size eight shoe. Right?

You probably wouldn’t say, “Oh, maybe I should have my feet resized. Maybe I don’t wear a size eight shoe.” That’s not what we as human beings do. Rather, we tend to become argumentative and defensive.

Dr. Amador uses the acronym LEAP: Listen, empathize, agree, and then partner.

When you’re listening to somebody, rather than responding with something like, “I hear that you’re not sick, but didn’t the doctor tell you that you should take medicine when you leave the hospital?”

You might instead try saying something like, “I understand that this is very frustrating for you. I’m sorry this has happened to you.” Notice that in the latter statement you’re not being critical, and you’re not being judgmental.

You’re listening and you’re empathizing. That’s it.

Most people, if you think about it, don’t do that. They’ll say “I hear you, but…” or “If you did it this way, it would be…” That is not engaging. People don’t want to hear that. They want to know that you hear them and that you’re empathizing with them. That you hear what they’re saying and that you’re not passing judgment or criticizing. They want to know that you are there for them, and that you will help them.

If disagreement continues around going to therapy, for instance, try saying something like “We don’t agree on the fact that you should go to therapy. However, you want to return to school, and I want to help you return to school. Is it okay if we both agree on the idea that you’re going to return to school and that we’re going identify what the barriers are to making that happen? We’ll simply agree to work on whatever those barriers are.”

P4SM: So identifying what the person’s goals are, and really focusing on those goals that are tangible and real to them?

Krista Baker: Exactly. If a person says, “I don’t have a problem. I didn’t go to the hospital because I wanted to. I got into a fight with my dad and he sent me to the hospital.” You could respond by saying, “Okay, I understand you feel you have a mental illness and we’re not going to discuss that issue. What I want to know is how was that experience for you?” If it turns out that it wasn’t good for them, and the person can agree that they don’t want to go back, you can ask, “Could we agree to work on making sure that you never return to the hospital again? Let’s talk about all the different things that might have contributed to you going to the hospital, and then we’ll pick some of those to work on.”

Rather than trying to talk somebody into agreeing with you, agree to find a common goal. The idea is to establish a partnership, in which you’re working together.

P4SM: Knowing how to listen non-judgmentally, and being able to identify common ground with people is a skill that can be applied in nearly any setting – from home to community to workplace. It definitely takes practice.

Krista Baker: Yes, this is a life skill with so many applications. We often think we’re going to talk someone into something, but ultimately this approach just ends up creating conflict and undermining the relationship. I can only imagine what a different world this would be if we paused to really listen to one another and respond empathetically.

 

Krista Baker, LCPC, is the creator and program supervisor of the Early Psychosis Intervention Clinic (EPIC) at Johns Hopkins Bayview Medical Center, a nationally recognized outpatient program for adolescents and young adults experiencing an initial psychotic episode. The EPIC program is designed to reduce the disabling effects of psychosis and assist individuals in reaching developmentally appropriate life goals. Ms. Baker has also collaborated in creating, and continues to supervise, the John Hopkins Bayview Adult Schizophrenia Clinic and Clozapine Clinic. She has become an advocate for improving Maryland mental health, testifying on behalf of those living with mental illness in front of state legislature and serves as a member of work groups developing a number of statewide mental health policy initiatives.

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