Assertive community-based case management
The central framework of PEPP-Montréal is an assertive community-based case management model that is modified to suit the needs of young people and their families. The same case manager is assigned to patients throughout their participation in the clinical program so as to foster the development of a strong therapeutic relationship.
The case manager utilizes a comprehensive medical and psychosocial approach to address the specific needs of the patient and does this in close partnership with the patient’s family. The case manager provides counselling and support to help patients understand and cope with the effects of their psychosis; and to help them return to work, school, and other meaningful community roles as soon as possible. Case managers often meet clients in the environment of their choice, including their homes.
Assessment and monitoring of symptoms
Patients receive regular clinical evaluations during their follow-up for two reasons:
- To monitor patient progress in terms of symptomatology (psychosis, depression, anxiety and mania) and related factors (substance use, quality of life, premorbid adjustment, family history, cognitive functioning, satisfaction with services, and side effects of medication)
- To systematically observe the early course of psychosis in the context of a comprehensive treatment program and publish the findings from these observations in research journals, when appropriate.
Medication treatment starts with the lowest possible dose of antipsychotic medication. The choice of antipsychotic medication is established through a treatment protocol that is explained to the patient and family by the psychiatrist. Clinical staff closely monitor side effects and assess them on a regular basis.
Medication may not immediately clear up all symptoms, but it is an important first step in the recovery process.
Cognitive behavioural therapy (CBT)
There is increasing evidence for the effectiveness of cognitive behavioural approaches in psychosis, particularly during the early stages of psychosis.
Cognitive behavioural therapy (CBT) is offered to help patients:
- Reduce the symptoms of psychosis
- Deal with problems of anxiety and depression
- Improve self-efficacy
- Reduce self-stigmatization
Generally, patients meet with their CBT therapist weekly for about one hour. The frequency of contact is tapered as the patient makes progress towards self-identified goals. The exact duration of CBT varies from one individual to another and ranges from 10 to 50 meetings.
Some of the techniques used in CBT are:
- Identifying, understanding, and modifying thoughts and beliefs
- Replacing old behaviours with new, more adaptive behaviours
- Activity scheduling
- Identifying and coping with triggers for psychosis
To successfully treat a first episode of psychosis, it may be helpful for a young person to receive in-patient care for a certain amount of time. In-patient care focuses on getting people better and home as soon as possible. The inpatient care is provided at the Burgess Pavilion, where a part of the unit has been modified to meet the specific needs of PEPP-Montréal clientele. It is equipped with two TV areas, a sports room, ping-pong tables, board games, and books.
PEPP-Montréal actively involves families in the treatment of their loved ones. This begins during the screening and assessment process where families are a valuable source of information and help PEPP staff to engage the client. Throughout the patient follow-up, families are invited to regularly meet with case managers and the treating psychiatrist to receive information, advice and support, and collaborate to improve treatment outcomes. Family psychoeducation workshops, multiple family group therapy, and family support groups are also offered.
Involvement in assessment and treatment planning
Families are invited and encouraged to attend screening and baseline assessment meetings with the psychiatrist, screening clinician, and case manager.
Case managers meet with families in the environment of their choice, including their homes. They also provide opportunities for families to talk about their concerns and their expectations of both treatment and their young family member with psychosis.
Individual support and intervention
Throughout the two-year follow-up, families meet with case managers and the treating psychiatrist to receive support and information.
Group family psychoeducation workshops
Families are offered group family psychoeducation workshops, which give them an opportunity to learn about psychosis and how they can support their loved ones’ recovery process.
The three two-hour workshops are led by a multidisciplinary team and deal with the following topics:
- What is psychosis?
- Psychosocial concern
Separate French and English workshops are provided three times a year. Case managers accompany the families they are working with to all these workshops. Case managers then meet individually with the families to help them assimilate the information, respond to their questions, and focus on priority concerns that the families identified during the workshops.
As part of the extended PEPP randomized controlled trial (lien page recherche). some patients continue to receive PEPP-Montréal services for an additional three years after the initial two years of treatment. Families of these clients receive booster psychoeducation sessions. There are two booster sessions in total: one led by a psychiatrist and the other by a case manager. The sessions are very interactive and encourage families to ask questions and share their experiences. Topics discussed include questions and concerns about treatment, expectations about recovery, and community reintegration following the two years of treatment at PEPP-Montréal.
Family Support Group
The Family Support Group is a peer-led group that consists of PEPP-Montréal family members and loved ones who get together once a month to discuss common issues and concerns and to offer mutual support and encouragement. This group also offers guidance and support to new families joining PEPP-Montréal. Meetings take place in the evening.
Multiple Family Group Therapy (MFT)
Multiple Family Group Therapy (MFT) is a recognized form of therapy that has been shown to reduce the risk of relapse and re-hospitalization rates for clients by up to 70%. MFT also improves problem solving skills, communication, and quality of life for patients and their loved ones. It builds on the strengths of families and loved ones to better assist in treatment and recovery. MFT is being offered to families who have been receiving services at PEPP-Montréal for over two years, as part of the extended PEPP randomized controlled trial.
Group interventions provide a range of meaningful and challenging activities in a supportive peer group environment to facilitate recovery. These activities include:
Recovery Through Activity and Participation (RAP)
Recovery Through Activity and Participation (RAP) involves simple activities designed for inpatients and outpatients still experiencing psychotic symptoms or who have difficulties with attention and thinking. RAP aims to:
- Enhance daily functioning
- Increase structure
- Promote the attainment of personal goals
This transitional activity-based group is held once a week for a maximum of twelve weeks. Currently, the RAP group uses the Roberts Recreation Centre at the Douglas Institute to incorporate organized team sports activities into therapy and promote better health through physical fitness, stress management, and socialization.
Creative Expressions Group
The Creative Expressions Group involves art activities designed especially for inpatients close to discharge as well as outpatients in their first year of treatment who are able to handle group structure and discussion. It aims to:
- Enhance daily functioning
- Increase structure
- Promote self-exploration and expression
- Promote the attainment of personal goals
The group meets once a week for one and a half hours and engages in artistic expression-based activities such as painting, drama, music and writing. The sessions are semi-structured, include some discussion and planning, and are oriented towards the goal of completing individual and group-based creative projects, such as a wall mural or a play.
Youth Education and Support (YES) Group
The goals of this group are to:
- Provide psychoeducation about first-episode psychosis
- Help patients learn to live with psychosis and negotiate identity issues
- Minimize relapse
- Strengthen peer support
- Educate patients on drug use and other issues relating to youth and psychosis
The YES group comprises five program sessions and is offered twice a year.
Meal Preparation and Nutrition Program
In collaboration with a Douglas Institute nutritionist and dietician, PEPP-Montréal offers workshops on a healthy lifestyle, balanced nutrition, healthy cooking, and quick and cost-effective meals. Patients also learn how to change their diet to reduce the weight gain often associated with medications for psychosis.
Individual Placement and Support (IPS) Program
Patients are referred to an IPS worker, who helps them find jobs, write CVs, prepare for interviews, and maintain employment. In collaboration with a case manager, the IPS worker works to improve patient employment outcomes.
Education is a key component in recovery and helps patients and their families understand what causes psychosis, how medications work, and how lifestyle habits—including the use of alcohol and drugs—can affect the illness. Patients also learn how to cope with symptoms and manage daily stress.
Figuring out how to cope with stress is another important ability in the recovery process. Everyone experiences stressful situations at some point in their lives, but even good stress (a graduation, wedding, or family event) can undermine the health of people living with psychosis. It is important to get information on stress management by talking to a physician or case manager or reading relevant material available in the Resource centre.
PEPP houses a resource centre that has a variety of helpful books, videos and brochures. A computer with Internet access and a printer is available for on-line resource consultations, job searches, CV preparation, and more.