Psychosocial Interventions for Psychotic Spectrum Disorders: Current Research and Connections to the Houston Community

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Introduction

This executive summary provides an overview of psychosocial interventions for psychotic spectrum disorders (PSDs), drawing from a presentation by Dr. Katherine Wick, Assistant Professor at Baylor College of Medicine. The presentation aimed to identify evidence-based psychosocial and psychotherapy interventions, summarize current research outcomes, and facilitate better utilization of local resources in Houston for individuals with PSDs.

Understanding Psychotic Spectrum Disorders (PSDs)

Psychotic spectrum disorders, also referred to as "psychosis," are specific disorders characterized by symptoms such as hallucinations, delusions, and/or disorganized thought, speech, or behavior. These disorders have a lifetime prevalence of approximately 3%, with onset typically occurring in late adolescence and early adulthood, though a small subset may develop "late-onset psychosis" after age 45.

PSDs are considered one of the most debilitating illnesses globally, ranking ahead of conditions like paraplegia and blindness in their interference with functioning and overall wellness. Individuals often experience ongoing difficulties in social roles, employment, and interpersonal relationships, even after acute symptoms have remitted.

Treatment Landscape for PSDs

While antipsychotic medications are the gold standard treatment for psychosis, a recent Cochrane review indicated that approximately 24% of patients relapse within one year of starting medication. This highlights a significant gap that psychosocial interventions are designed to address, aligning with various clinical guidelines. Electroconvulsive therapy (ECT) is also a recognized treatment but was not the focus of this discussion.

Psychotherapy is highly recommended by numerous clinical guidelines, considered a gold standard intervention in countries including New Zealand, Australia, the US, Germany, and the UK. However, a 2023 meta-analysis of 22 studies across nine countries revealed remarkably low rates of service provision and receipt for two key gold-standard psychotherapy interventions:

• Cognitive Behavioral Therapy for Psychosis (CBTp): Only 23% of surveyed individuals were offered CBTp, and only 24% received it.
• Family-based interventions: Only 30% received this support.

Despite these low overall rates, there was an increased rate (around 41%) of CBTp receipt in early intervention studies for individuals at clinical high risk or experiencing first-episode psychosis. Conversely, family intervention rates remained low (around 32%) in these early stages, representing a missed opportunity, especially given the typically higher family involvement with younger patients.

The meta-analysis did not find significant effects of age, gender, ethnicity, diagnosis, or marital status on therapy receipt. A notable limitation was the lack of data from South America, Africa, and Asia, indicating a need for broader research to understand global gaps.

Key Psychosocial Interventions

There are several effective psychosocial interventions available that address this gap:

• Cognitive Behavioral Therapy for Psychosis (CBTp):
  • Description: This treatment aims to reduce psychosis-related distress, thoughts, and hallucinations by changing and monitoring assumptions, helping individuals to more accurately reflect reality. It posits that core beliefs and schemas can be targeted to increase flexibility and grounding, thereby improving symptoms.
  • Efficacy: Researched for over 30 years, CBTp has been found to be effective. More recent meta-analyses (last 10 years) show small to medium effects on both positive and negative symptoms. Importantly, outcomes have been improving over time, particularly in reducing delusions, suggesting that the intervention and clinician proficiency are evolving. CBTp is also a top intervention for increasing insight in individuals with PSDs, which is crucial for questioning and challenging delusions.
  • Improvements: To enhance effectiveness, researchers have found the importance of individualizing treatment (making it less manualized) and focusing on common therapeutic factors. These common factors, vital for successful therapeutic interventions across different modalities, include therapeutic alliance, empathy, therapist difference, patient expectations, and cultural adaptation. A strong therapeutic alliance significantly improves treatment engagement and leads to better global symptom ratings, including positive and negative symptoms of psychosis, depression, and anxiety.
• Metacognitive Therapy for Psychosis (MCTp):
  • Description: A relatively new (20-25 years old) structured, manualized approach combining psychoeducation, cognitive modifications, and tool teaching, grounded in CBT principles.
  • Efficacy: A 2022 meta-analysis of 43 studies found MCT to be associated with improvements in positive symptoms (delusions, hallucinations), self-esteem, negative symptoms, and overall functioning. These improvements were sustained for approximately one year. MCT has small but positive effects on global social cognition and theory of mind, which are crucial for navigating the world, processing information, and making reality-grounded decisions. Social cognition encompasses theory of mind, emotion processing, attributional style, and social perception, all of which are significantly impacted by psychosis.
• Family Interventions:
  • Description: These are wide-ranging interventions, typically therapist- or peer-supported, targeted at the family of the person experiencing psychosis. Their purpose is to help families cope with their experiences, understand symptoms through psychoeducation, and guide and support their loved one through the illness.
  • Efficacy: For clinical high-risk or early-onset psychosis, interventions often include extensive family support and psychoeducation. Project Reach, a CBT-based family intervention from Stanford University, showed promising initial results, reducing caregiver depression, anxiety, expressed emotion, and negative perceptions of caregiving, while increasing pro-social attitudes (e.g., believing the family member can achieve their desired life with support), even with brief interventions like monthly or weekly follow-ups. These programs can also be affordable, some even free as part of research studies. For individuals who have experienced psychosis for a longer time, family interventions are still considered gold standard and highly effective, helping to reduce hospitalization rates. However, engaging families in these contexts can be more challenging due to potentially less frequent family involvement.
• Cognitive Remediation:
  • Description: Designed to treat cognitive symptoms associated with psychosis, such as problems with attention, short-term memory, executive functioning, planning, social cognition, and metacognition. These impairments significantly affect daily functioning, impacting tasks like getting ready in the morning or planning meals.
  • Efficacy: A large-scale 2021 meta-analysis found small to moderate effects across various cognitive outcomes, including attention, memory, executive functioning, social cognition, and metacognition. Crucially, these cognitive gains were associated with improvements in real-world functioning. While computerized programs can improve cognitive skills in the short term, their generalization to real-world tasks is enhanced through "bridging groups". These groups allow individuals to practice skills, including social skills and functional tasks (e.g., navigating public transport), through role-modeling and rehearsal. Even greater real-world functional improvement is observed when individuals have opportunities to practice these skills in the community with a supportive person.
• Social Skills Training:
  • Description: Addresses significant social impairments often seen with negative symptoms of PSDs, such as challenges in expressing or reading emotions, apathy, and reduced interest in social activities. These trainings typically involve role-modeling, positive reinforcement, and behavioral rehearsals to improve social perception, cognition, and behavioral responses. This includes practicing conversations, navigating disagreements, and asserting boundaries.
  • Efficacy: Considered a gold standard intervention for PSDs, commonly delivered in group settings. A recent meta-analysis showed that social skills training improved core illness symptoms and negative symptoms when compared to standard treatment. Notably, attendance rates for psychosis-focused groups were found to be like those for other mental health groups (e.g., depression, anxiety), suggesting that offering these groups is key to engagement.

Connecting to Houston Community Resources

A critical aspect of improving outcomes for individuals with PSDs is connecting them to available resources. The following is a non-exhaustive list of Houston-based organizations and programs, acknowledging that programs evolve and finding specialized services can be challenging:

• For Low-Income, Unhoused Populations, and those with Limited Access to Services:
  • Support Treatment and Rehabilitation (STAR) Program: An indefinite, open, 2-day-a-week in-person group program for adults (18+), requiring qualification through Harris Health services (in-network insurance).
  • Early Onset Psychosis Program (EOPP) through the Harris Center: A coordinated specialty care program (including psychiatry, psychology, social workers, peer support, occupational therapists) for ages 15-30. It's an outpatient program allowing individuals to stay for up to three years.
  • Mobile Crisis Outreach Team (MCOT) through the Harris Center: Several teams available for acute psychiatric crises, providing quick assessment.
  • St. Joseph Clubhouse: A community-based psychosocial support and engagement program offering enjoyable and social activities, alongside information and support for housing, affordable food, and employment.
• Insurance-Based Options:
  • Psychosis Specialty Clinic at UT Health: An outpatient program specializing in treating psychosis and PSDs.
  • Long-Term Inpatient Program (Recovery Oriented Treatment Program) through UT Health: A residential-style inpatient program allowing extended stays (potentially up to a year) for comprehensive support.
  • Meninger Clinic: Offers inpatient, outpatient, and assessment services for various PSDs.
• For Veteran Populations (through the VA):
  • Bipolar and Schizophrenia Treatment (BEST) Clinic.
  • Psychosocial Rehabilitation and Recovery Center (PRRC).
• Private Practice Providers: Available in the Houston area, though often requiring individual search.

The presenter strongly advocates for collaboration among clinicians and community members to create a more comprehensive referral list, as the current low rates of people receiving vital psychotherapy interventions (25-30%) are unacceptable. Sharing additional resources would enable better patient connection and improve overall care.

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