Early Psychosis Intervention: A Culturally Adaptive Clinical Guide

29. Recovery from Psychosis

The development of antipsychotics in the 1950s marked the turning point in the treatment of psychosis. Since then, there has been a progressive increase in expectations for treatment outcomes in psychotic disorders. In the pre-1960s era, the goal of treatment was simply “improvement in self-care and reduction in aggression and self-injury”. With time, this goal has changed to “deinstitutionalization ” in the 1960s and 1970s, and to “reduction of recidivism and minimization of positive symptoms” in the 1980s. From the 1990s onward, the ultimate goal of the treatment of psychosis has advanced to the “increase in periods of stabilization, minimization of negative symptoms and reduction of side-effect burden”. Nowadays, the long-term management aim of psychosis should at least include optimization of quality of life, helping clients to regain their former level of independence, encouragement of integration into the society, as well as minimization of relapse (Taylor et al., 2005). In promoting recovery especially in people with early psychosis, services should be enabling rather than disabling , ultimately aspiring to healing and recovery. Clients need encouragement and sufficient support to retain or regain full participation in society (Bertolote & McGorry, 2005). Remission and Recovery In clinical research, attempts have been made to define criteria for remission of psychosis. A proposed definition of remission from the illness process is absence of symptoms, or presence of only minimal symptoms, in major psychopathology dimensions including psychotic symptoms (delusions, hallucinations, and unusual thought content), disorganization (conceptual disorganization and mannerisms or posturing), and negative symptoms (blunted affect, social 29 Recovery from Psychosis Chi-wing Law 324 Chi-wing Law withdrawal, and lack of spontaneity) for more than six months (Andreasen et al., 2005). The concept of recovery, however, seems to be more vaguely defined. Recovery refers not only to the client being free from symptoms, but also returning to reasonable functioning levels. Remission is considered a necessary but not sufficient step towards recovery, which is a higher hurdle and longerterm goal. Possible future definition of recovery is expected to be operationalized in the sense of moving forward and rebuilding one’s life and is likely to incorporate improvements in other areas, such as empowerment, quality of life, and psychosocial functioning (van Os et al., 2006). Another effort to standardize the criteria of recovery was proposed by Liberman et al. (2002). Their definition includes both a clinical criterion, which specifies the limit of Brief Psychiatric Rating Score (BPRS) score for different items, and a functioning criterion, which specifies participation in occupational and social aspects of life. Bellack (2006) has commented that this definition of recovery suggests that total symptom remission is not absolutely necessary for recovery; instead, it can be attained even with mild to moderate symptoms. It is possible that some people have periods of good functioning while also having intermittent exacerbations of clinical symptoms. Clients undergoing the process of recovery need to face a number of challenges as their active symptoms remit. These complex issues include the appraisal of the extent of recovery and the possibility of relapse, as well as making sense of the illness episode and its treatment (Andresen, Oades, & Caputi, 2003; Sells, Stayner, & Davidson, 2004). These interconnected issues, on the other hand, are potentially open to the influence of prior knowledge about the illness, personality of the client in the premorbid state, sociocultural influences, experiences of the illness process, as well as psychoeducational messages delivered by the intervention team during the process of treatment (Roe et al., 2004; Sells et al., 2004; Strauss, 1994; White et al., 2000). Discrepancy in Expectations The meanings and expectations of recovery from psychosis could differ among different clients, caregivers, and health professionals. Even among different health professionals, their focus in the recovery process could also vary. Clinicians would be more concerned about symptom control, degree of medication side-effects, etc., whereas other disciplines such as social workers may be paying more attention towards the clients’ employment and relationship Recovery from Psychosis 325 with others. The expectation of recovery would also be constantly changing during different phases of the illness. In everyday clinical practice, health professionals do not often raise the issue of recovery during the interview session. On the other hand, clients and their caregivers may be expecting more discussion in this aspect, but find it hard to raise this issue in a brief clinical follow-up session with clinicians. Moreover, clients with significant residual and negative symptoms, and thus most in...