5-minute first aid for psychosis

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5-minute first aid for psychosis

Author(s)

Narsimha R. Pinninti, MBBS, MD

Neal Stolar, MD, PhD

Scott Temple, PhD

Adding just 5 to 10 minutes of psychotherapy to medication monitoring visits can help patients overcome hallucinations, delusions, and other psychotic symptoms. Targeted cognitive-behavioral therapy (CBT) can:

prevent crisis visits and hospitalizations
improve long-term medication and treatment adherence
enhance the therapeutic alliance.

Treatment goals for patients with chronic mental illness are changing as clinicians, patients, and families aspire for more than improved symptoms ( Box ).^1-14 This article describes brief interventions to target medication nonadherence and positive and negative symptoms in patients with schizophrenia, schizoaffective disorder, bipolar disorder, major depressive disorder, and other chronic disorders.

CASE: VOICES FROM THE PAST

Ms. W, age 45, is seen every 6 to 8 weeks in an outpatient medication management clinic for symptoms of schizoaffective disorder, depressed type; posttraumatic stress disorder; and generalized anxiety disorder. She has a history of severe abuse by her father, self-mutilation in response to anxiety and stress, and repeated hospitalizations following visits to her mother.

She recently visited her mother again and saw her father as well. The trip led to increased symptoms of intrusive traumatic memories, thoughts of suicide with plans to overdose, visual hallucinations of her father, and increased auditory hallucinations with derogatory content.

Goals of the first therapy session after Ms. W’s trip home were to reduce her suicidal thoughts and prevent hospitalization. We encouraged her to list her positive qualities, accomplishments, important relationships, religious beliefs, goals, and dreams. She then wrote all these reasons to live on a cue card. Reading the card twice in the session stopped her suicidal thoughts, and she expressed some hope.

We encouraged her to read the card whenever suicidal ideas became strong. We scheduled her next visit 1 week later, and she contracted not to attempt suicide during that time.

DEVELOPING AN ALLIANCE

To develop an alliance with psychotic patients such as Ms. W, the first task is to help them leave each session feeling understood, validated, and enjoying the therapist’s company. This alone provides a powerful counterbalance to the isolation, demoralization, and hopelessness they bring to therapy.

Box

Why drug therapy alone is not enough

Pharmacologic and psychosocial interventions are changing treatment goals for patients with serious mental illness from improved symptoms to functional recovery, improved quality of life, and reintegration into the community.^1,2 Patients, families and clinicians increasingly view self-determination, independence, and recovery as realistic treatment goals.^3,4

Medication limits. Drugs are crucial to managing psychotic symptoms but inadequate for achieving recovery:

many patients with positive psychotic symptoms respond only partially or not at all⁵
functional improvement does not always follow symptomatic improvement⁶
medication nonadherence remains high, leading to repeated relapses.⁷

Dual-therapy benefits. A combination of antipsychotics and psychotherapy has been found to increase the chances of recovery in schizophrenia.⁸ Psychotherapy is also highly valued by patients and their families:

In patient satisfaction studies, 72% to 90% of participants with psychotic disorders said individual psychotherapy improved their lives.^9,10
In a survey of 3,099 National Alliance for the Mentally Ill family members, 88% rated psychotherapy as having some (53%) or considerable (35%) value.¹¹

Access problems. Despite psychotherapy’s benefits, access is extremely limited. In one survey, only 7.3% of patients with nonaffective psychosis received at least “minimally adequate” care (four or more medication visits that did not include psychotherapy).¹² Incorporating therapeutic techniques into medication monitoring clinics is one way to improve access to therapy for patients with serious mental illnesses.

Keep it brief. Psychotherapy in medication clinics differs from traditional models’ 15- to 45-minute sessions.¹³ Patients with psychotic illness prefer brief interventions; a study of 212 patients found that 85% of those with schizophrenia preferred sessions:

less often than once a week
that focus on solving practical problems.¹⁴

Table 1

5 steps in effective cognitive-behavioral interventions

Identify the problem the patient wants to work on and narrow it down Rate the identified symptom or issue, where possible using a simple 0 to 10 rating scale Choose and use an intervention Rate the target symptom again, and get patient feedback Ask patient to write down what is learned on a card or in a notebook, and give patient an assignment to reinforce learning at home

Four principles for dealing with psychosis are normalization, universality, collaborative therapeutic alliance, and focusing on the patient’s life goals:

In normalization, the stress vulnerability model is used to explain psychosis to the patient. Psychotic symptoms are emphasized as something normal people can experience in extreme situations, such as:

hallucinations in states of sleep deprivation or medical and drug-induced states
paranoia as error in thinking in states of heightened vigilance and perceived threat.¹⁵

Universality is the understanding that many people have experiences similar to the patient’s.

In a collaborative therapeutic alliance, the patient is not a passive recipient but an active collaborator in therapy. He or she contributes to decisions—such as the length of therapy and topics to be discussed—and gives feedback on interventions and therapist style.

Focusing on life goals makes therapy meaningful to the patient.

Set priorities. Because only one or two therapeutic interventions can be tried during a medication-monitoring visit, problems need to be prioritized. As with Ms. W, the first visit’s goal was crisis intervention: to reduce suicidal thoughts and prevent hospitalization. Table 1 offers a framework for effective therapeutic interventions.

Save time by giving patients out-of-session assignments, which:

collect important information to review with patients during the next monitoring session
help empower patients to manage their symptoms.

Adaptive strategies—such as drill and practice¹⁷—can help improve learning in patients with cognitive impairment, which is common in psychotic disorders.¹⁶ Give the patient a pocket notebook to write down what he learns in sessions, and encourage him to review the material at home. Call this a book of coping skills.

IMPROVING ADHERENCE

Medication nonadherence and partial adherence can result from:

illness-related factors such as lack of insight
patient-related factors such as attitudes and beliefs about medication
treatment factors such as side effects
physician-related factors such as showing an authoritarian attitude toward patients
system-related factors such as treatment access problems.

Interventions that respect individual autonomy and responsibility enhance long-term adherence ( Table 2 ), whereas those that invoke fear—such as threats of hospitalization—are ineffective and demoralizing. Improved medication adherence can reduce hospitalization and health care costs.¹⁸

Table 2

Interventions to improve patient medication adherence

Issue	Intervention
Assessing medication adherence and beliefs	Specific questions (“Did you miss any doses since we last met?”) give most-accurate information Questions such as “What does taking medication mean to you?” help clarify patients’ beliefs
Dysfunctional beliefs about medication (“Taking it means I am weak.” “It can turn me into a zombie.” “I will be dependent on medication.”)	With the patient, examine evidence for dysfunctional beliefs about medication Acknowledge possible adverse effects; encourage patient to persist through mild side effects Provide objective information about the medication, including views of patients who did well on it
Lack of insight (“I do not need medication”)	Help patient identify early subjective psychotic symptoms (insomnia, restlessness, racing thoughts) Encourage patient to examine what life is like when on versus off medication Have patient ask a trusted family member or friend how he or she is different on and off medication
Forgetting to take medication	Help patient set up medication routine and stick with it Advise patient to buy an alarm clock and set it to sound when medication is to be taken Encourage patient to keep medication in a prominent place, such as at bedside Encourage him/her to use a medication organizer
Lack of a shared understanding of the illness between patient and physician	Encourage patient to state why he/she takes medication Explore patient’s understanding of the diagnosis Develop an explanation that makes sense to the patient and provides a reason to take the medication (such as, “Medication can help me achieve my goals”)

CASE: NOT REALLY HER FATHER

By the second session 1 week later, Ms. W’s suicidal thoughts had become infrequent and mild, and she was using the coping card as needed. This visit focused on visual hallucinations associated with anxiety about facing her father. We encouraged her to describe the hallucinations in great detail, and she realized that she visualized her father as he had looked 20 years ago, not as he looks today. Her anxiety decreased as she considered that she might be seeing not him but an image. Her homework assignment was to closely observe the hallucinations. Because she was more stable, the next visit was scheduled in 2 weeks.

By the third session, she reported that the visual hallucinations had disappeared, and the focusing technique had helped her. She continued to hear voices, however, particularly in the evening when she was alone and anxious or depressed. With prompting, she identified activities she could engage in at night, such as calling her mother and praying with her mother on the phone. This reduced her loneliness and helped her relax.

Table 3

Interventions to manage auditory and visual hallucinations

Problem	Intervention
Acting on hallucinations	Ask questions such as:
	“What do you say to yourself when the voices command you and you ignore them?” “What do you say to yourself when the voices command you and you follow the command?”
	Tell patient, “It is not the voices themselves but the thoughts in your mind in response to the voices that determine whether or not you follow them”
	List thoughts patient generates when choosing not to follow voice commands and encourage patient to read the list when hearing voices
Triggers of negative emotions that cause voices	Ask questions such as:
	“What kind of moods bring on the voices?” “Are the voices more likely to be triggered by anxiety, anger, frustration, or boredom?” “Can you keep track of what triggers the voices from now to the next visit?”
	Identify techniques to deal with triggers and rate their effectiveness
Dysfunctional beliefs that voices cannot be controlled or are prophetic	When voices are strong, coach patient to rate them on a scale of 0 to 10, try different distraction techniques, and rate them again
	Encourage patient to write down what the voices say and whether their prophecies come true; reviewing the record in subsequent session shows voices are not prophetic
Voices during the session	Hum a familiar tune with patient
Voices during the session	Ask patient to read out loud
Visual hallucinations	Encourage patient to examine details of what they see; this alone can make hallucinations disappear
Visual hallucinations	Encourage patient to try to make hallucinations funny, such as making the image’s nose long (personal communication: e-mail Morton Sosland MD)

One month later, the voices had diminished greatly, and Ms. W returned to her regular medication monitoring appointments of every 6 to 8 weeks.

MANAGING POSITIVE SYMPTOMS

In serious mental illnesses such as schizophrenia, the most common hallucinations are auditory ( Table 3 ),¹⁹ followed by visual and other types.²⁰ Sometimes patients view hallucinations as helpful, providing reassurance, advice, or companionship. The content may be an expression of the patient’s own beliefs.

Table 4

Interventions to help patients examine common delusions

Symptom	Questions to ask the patient
Behaviors of acting on delusions	“Let’s examine how your belief and behavior in response to it affect your life, both positive and negative” “Is this belief helping you advance in life or hindering you?” “Is this belief helping you reach your goals?”
Delusion with changing conviction	“When does this belief bother you the most?” “When does this belief bother you the least?” “How are you feeling right this minute? Is it bothering you at all?” “What is it about some situations that make you less bothered by this belief?”
Delusion with complete conviction	“When did you first have these thoughts?” “Did you believe in them right away, or did you have doubts?” “What were some of the doubts you had?” “Do you still have those doubts?”
Addressing underlying beliefs	“What does it mean to you to believe in this?” “How would life be different if you did not have this belief?”
Delusion associated with lack of real world knowledge	Provide real-world knowledge. For example, for delusion that people can read a patient’s mind, inform patient that scientific experiments have shown that no one can read complex thoughts of others
Delusion involving physician	For example, say, “It is normal for you to sometimes question my intentions and believe that I am part of the conspiracy. I can assure you that is not the case. Anytime you have those doubts I would like the opportunity to clarify those for you. Can I rely on you to bring those doubts to my attention?”
Delusion involving physician	When patient’s body language or behavior changes, ask if patient is suspicious and paranoid about you
Behavioral experiment for delusions	For example, a patient believed people parking cars on his street would break into his apartment. Homework was designed with two columns on a paper, one for him to check when someone parked and the other if they broke in. Next visit, patient returned with no checks in the break-ins column

When a patient such as Ms. W has hallucinations, consider four questions:

Are the hallucinations distressing, and does the patient want them to stop?
What triggers them (usually depressed mood, anxiety, anger, or boredom)?
What coping mechanisms has the patient used, and how effective have they been?
What is the source of the patient’s distress?

Patients may be distressed by the hallucinations’ content or by their belief that they lack control over them. When you identify negative emotions as a trigger, focus on interventions to deal with those emotions.

Table 5

Interventions for managing schizophrenia’s negative symptoms

Symptom	Intervention
Anergia/anhedonia	With the patient, list activities he thinks he can do daily Have the patient rate his pleasure and competence on a 10-point scale every time an activity is completed Tie accomplishing daily activities to patient’s long-term goals Ask a family member to encourage patient to stick to the schedule Examine automatic thoughts relating to expectations of failure
Impaired attention	Identify specific situations where attention needs to be improved Identify environmental factors that interfere with attention and encourage patient to make appropriate changes Encourage patient to read a passage in session and recap what he read; start with 2 or 3 minutes and gradually increase the duration Try loud reading if silent reading does not help
Alogia	Link effective communication to patient’s goals Make pact with patient not to answer in monosyllables Avoid yes/no questions Ask him to educate you on a topic that interests him; give positive feedback for increased speech output

Delusions tend to develop gradually, and patients initially doubt them. Even when delusions are very firm, situations can change the strength of conviction. Base interventions on logical responses to delusions ( Table 4 ) and the patient’s coping skills. Sometimes they experience delusions because they lack real-world knowledge.

Never dispute a patient’s delusional beliefs. Maintain an attitude of benevolent curiosity to elicit the reasoning processes by which he or she came to believe the delusions. By encouraging the patient to become curious about the experience, you can create a chink of insight and help the him or her achieve important goals despite disturbing sensory experiences and beliefs.

Thought disorder can be addressed by gently pointing out that you are having trouble understanding the patient’s speech. Ask if other people whom the patient trusts have commented on his or her speech.

Because thought disorder worsens the longer a patient talks, suggest a 5-sentence rule during sessions. You and the patient try to speak no more than 5 sentences at a time before pausing to let the other person speak. Encourage the patient to monitor your speech and to indicate when you violate the rule. Monitoring your speech helps patients start monitoring their own.

Thought disorder worsens when patients experience negative emotions such as anxiety. When this occurs, move the discussion to a neutral topic or encourage deep regular breathing for 2 minutes to reduce anxiety.

MANAGING NEGATIVE SYMPTOMS

Negative symptoms of schizophrenia ( Table 5 ) overlap with depression and with medication side effects. Anhedonia and social withdrawal, for example, may reflect a patient’s depression and demoralization, rather than just schizophrenia’s biological core symptoms.

Similarly, limited facial expression may be caused by drug side effects, rather than absence of affect. Negative symptoms also can occur in the absence of depression or side effects, such as when a patient’s automatic thoughts related to expectations of failure lead to lack of motivation.

Negative symptoms usually bother patients much less than positive symptoms do. Thus, enlisting family members to help patients monitor and deal with negative symptoms can be very useful.

CASE SUMMARY

Ms. W’s stress-related psychotic symptoms resolved to baseline with cognitive therapy done in a regular medication management clinic. Throughout this episode, her medication dosages remained unchanged. The interventions added about 10 minutes to sessions, effectively dealt with her symptom exacerbation, and prevented hospitalization.

Psychotropics remain a critical component of treating psychotic disorders, and psychotherapy can also be very helpful. But in the many situations when psychotherapy is not available, brief psychotherapeutic techniques can:

increase patient and family satisfaction
enhance the therapeutic alliance
improve medication adherence
promote recovery.

References

1. American Psychiatric Association. Work group on Schizophrenia. Practice guidelines for the treatment of patients with schizophrenia. Am J Psychiatry 2004;161:29(suppl):26-7.

2. Kane JM. Long-term treatment of schizophrenia: moving from a relapse-prevention model to a recovery model. J Clin Psychiatry 2004;64(11):1384-5.

3. Coursey RD, Alford J, Safarjan B. Significant advances in understanding and treating serious mental lllness. Prof Psychol Res Pract 1997;28(3):205-16.

4. Cunningham R. In my own voice: how early intervention led to great success. NAMI Voice 2004;1:1-5.

5. Conley RR, Buchanan RW. Evaluation of treatment-resistant schizophrenia. Schizophr Bull 1997;23:663-74.

6. Harvey PD, Green M, Keefe RS, Velligan DI. Cognitive functioning in schizophrenia: a consensus statement on its role in the definition and evaluation of effective treatments for the illness. J Clin Psychiatry 2004;65(3):361-72.

7. Bridge JA, Barbe RP. Reducing hospital readmission in depression and schizophrenia: current evidence. Curr Opin Psychiatry 2004;17(6):505-11.

8. Lieberman RP, Kopelowicz A, Ventura J, et al. Operational criteria and factors related to recovery from schizophrenia. Int Rev Psychiatry 2002;14(4):256-72.

9. Leggatt M. Schizophrenia: the consumer’s viewpoint. In: Burrows GD, Norman TR, Rubinstein G (eds). Handbook of studies on schizophrenia, vol 2. New York: Elsevier Science Publishers, 1986;143-53.

10. Coursey RD, Keller AB, Farrell EW. Individual psychotherapy and persons with serious mental illness: the client’s perspective. Schizophr Bull 1995;21:283-301.

11. Hatfield A, Gearon J, Coursey R. Family members’ ratings of the use and value of mental health services: results of a national NAMI survey. Psychiatr Serv 1996;47:825-31.

12. Wang PS, Demler O, Kessler RC. Adequacy of treatment for serious mental illness in the United States. Am J Public Health 2002;92(1):92-8.

13. Rector N, Beck A. CBT for schizophrenia. Can J Psychiatry 2002;47(1):39-48.

14. Coursey RD, Keller A, Farrell EW. Individual psychotherapy and serious mental illness: the clients’ perspective. Schizophr Bull 1995;21:283-301.

15. Kingdon DG, Turkington D. Explanations of schizophrenia. In: Kingdon DG, Turkington D (eds). Cognitive-behavioral therapy of schizophrenia. New York: Guilford Press, 1994;9.-

16. Green MF. What are the functional consequences of neurocognitive deficits in schizophrenia? Am J Psychiatry. 1996;153:361-9.

17. Velligan DI, Bow-Thomas CC, Huntzinger C, et al. Randomized controlled trial of the use of compensatory strategies to enhance adaptive functioning in outpatients with schizophrenia. Am J Psychiatry 2000;157:1317-23.

18. Gilmer T, Dolder C, Lacro J, et al. Adherence to treatment with antipsychotic medication and health care costs among Medicaid beneficiaries with schizophrenia. Am J Psychiatry 2004;161(4):692-99.

19. Romme MAJ. Hearing voices. Schizophr Bull 1989;15:209-16.

20. Andreasen NC, Flaum M. Schizophrenia: the characteristic symptoms. Schizophr Bull 1991;17(1):27-49.

Author and Disclosure Information

Narsimha R. Pinninti, MBBS, MD
Assistant professor of psychiatry School of Osteopathic Medicine University of Medicine and Dentistry of New Jersey Medical director, Steininger Behavioral Care Services Cherry Hill, NJ

Neal Stolar, MD, PhD
Clinical associate professor of psychiatry University of Pennsylvania, Philadelphia

Scott Temple, PhD
Clinical associate professor Department of psychiatry University of Iowa Hospitals and Clinics Iowa City, Iowa

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Current Psychiatry

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Reviews

Author(s)

Narsimha R. Pinninti, MBBS, MD

Neal Stolar, MD, PhD

Scott Temple, PhD

Author(s)

Narsimha R. Pinninti, MBBS, MD

Neal Stolar, MD, PhD

Scott Temple, PhD

Author and Disclosure Information

Narsimha R. Pinninti, MBBS, MD
Assistant professor of psychiatry School of Osteopathic Medicine University of Medicine and Dentistry of New Jersey Medical director, Steininger Behavioral Care Services Cherry Hill, NJ

Neal Stolar, MD, PhD
Clinical associate professor of psychiatry University of Pennsylvania, Philadelphia

Scott Temple, PhD
Clinical associate professor Department of psychiatry University of Iowa Hospitals and Clinics Iowa City, Iowa

Author and Disclosure Information

Narsimha R. Pinninti, MBBS, MD
Assistant professor of psychiatry School of Osteopathic Medicine University of Medicine and Dentistry of New Jersey Medical director, Steininger Behavioral Care Services Cherry Hill, NJ

Neal Stolar, MD, PhD
Clinical associate professor of psychiatry University of Pennsylvania, Philadelphia

Scott Temple, PhD
Clinical associate professor Department of psychiatry University of Iowa Hospitals and Clinics Iowa City, Iowa

Adding just 5 to 10 minutes of psychotherapy to medication monitoring visits can help patients overcome hallucinations, delusions, and other psychotic symptoms. Targeted cognitive-behavioral therapy (CBT) can:

prevent crisis visits and hospitalizations
improve long-term medication and treatment adherence
enhance the therapeutic alliance.

Treatment goals for patients with chronic mental illness are changing as clinicians, patients, and families aspire for more than improved symptoms ( Box ).^1-14 This article describes brief interventions to target medication nonadherence and positive and negative symptoms in patients with schizophrenia, schizoaffective disorder, bipolar disorder, major depressive disorder, and other chronic disorders.

CASE: VOICES FROM THE PAST

Ms. W, age 45, is seen every 6 to 8 weeks in an outpatient medication management clinic for symptoms of schizoaffective disorder, depressed type; posttraumatic stress disorder; and generalized anxiety disorder. She has a history of severe abuse by her father, self-mutilation in response to anxiety and stress, and repeated hospitalizations following visits to her mother.

She recently visited her mother again and saw her father as well. The trip led to increased symptoms of intrusive traumatic memories, thoughts of suicide with plans to overdose, visual hallucinations of her father, and increased auditory hallucinations with derogatory content.

Goals of the first therapy session after Ms. W’s trip home were to reduce her suicidal thoughts and prevent hospitalization. We encouraged her to list her positive qualities, accomplishments, important relationships, religious beliefs, goals, and dreams. She then wrote all these reasons to live on a cue card. Reading the card twice in the session stopped her suicidal thoughts, and she expressed some hope.

We encouraged her to read the card whenever suicidal ideas became strong. We scheduled her next visit 1 week later, and she contracted not to attempt suicide during that time.

DEVELOPING AN ALLIANCE

To develop an alliance with psychotic patients such as Ms. W, the first task is to help them leave each session feeling understood, validated, and enjoying the therapist’s company. This alone provides a powerful counterbalance to the isolation, demoralization, and hopelessness they bring to therapy.

Box

Why drug therapy alone is not enough

Pharmacologic and psychosocial interventions are changing treatment goals for patients with serious mental illness from improved symptoms to functional recovery, improved quality of life, and reintegration into the community.^1,2 Patients, families and clinicians increasingly view self-determination, independence, and recovery as realistic treatment goals.^3,4

Medication limits. Drugs are crucial to managing psychotic symptoms but inadequate for achieving recovery:

many patients with positive psychotic symptoms respond only partially or not at all⁵
functional improvement does not always follow symptomatic improvement⁶
medication nonadherence remains high, leading to repeated relapses.⁷

Dual-therapy benefits. A combination of antipsychotics and psychotherapy has been found to increase the chances of recovery in schizophrenia.⁸ Psychotherapy is also highly valued by patients and their families:

In patient satisfaction studies, 72% to 90% of participants with psychotic disorders said individual psychotherapy improved their lives.^9,10
In a survey of 3,099 National Alliance for the Mentally Ill family members, 88% rated psychotherapy as having some (53%) or considerable (35%) value.¹¹

Access problems. Despite psychotherapy’s benefits, access is extremely limited. In one survey, only 7.3% of patients with nonaffective psychosis received at least “minimally adequate” care (four or more medication visits that did not include psychotherapy).¹² Incorporating therapeutic techniques into medication monitoring clinics is one way to improve access to therapy for patients with serious mental illnesses.

Keep it brief. Psychotherapy in medication clinics differs from traditional models’ 15- to 45-minute sessions.¹³ Patients with psychotic illness prefer brief interventions; a study of 212 patients found that 85% of those with schizophrenia preferred sessions:

less often than once a week
that focus on solving practical problems.¹⁴

Table 1

5 steps in effective cognitive-behavioral interventions

Identify the problem the patient wants to work on and narrow it down Rate the identified symptom or issue, where possible using a simple 0 to 10 rating scale Choose and use an intervention Rate the target symptom again, and get patient feedback Ask patient to write down what is learned on a card or in a notebook, and give patient an assignment to reinforce learning at home

Four principles for dealing with psychosis are normalization, universality, collaborative therapeutic alliance, and focusing on the patient’s life goals:

In normalization, the stress vulnerability model is used to explain psychosis to the patient. Psychotic symptoms are emphasized as something normal people can experience in extreme situations, such as:

hallucinations in states of sleep deprivation or medical and drug-induced states
paranoia as error in thinking in states of heightened vigilance and perceived threat.¹⁵

Universality is the understanding that many people have experiences similar to the patient’s.

In a collaborative therapeutic alliance, the patient is not a passive recipient but an active collaborator in therapy. He or she contributes to decisions—such as the length of therapy and topics to be discussed—and gives feedback on interventions and therapist style.

Focusing on life goals makes therapy meaningful to the patient.

Set priorities. Because only one or two therapeutic interventions can be tried during a medication-monitoring visit, problems need to be prioritized. As with Ms. W, the first visit’s goal was crisis intervention: to reduce suicidal thoughts and prevent hospitalization. Table 1 offers a framework for effective therapeutic interventions.

Save time by giving patients out-of-session assignments, which:

collect important information to review with patients during the next monitoring session
help empower patients to manage their symptoms.

Adaptive strategies—such as drill and practice¹⁷—can help improve learning in patients with cognitive impairment, which is common in psychotic disorders.¹⁶ Give the patient a pocket notebook to write down what he learns in sessions, and encourage him to review the material at home. Call this a book of coping skills.

IMPROVING ADHERENCE

Medication nonadherence and partial adherence can result from:

illness-related factors such as lack of insight
patient-related factors such as attitudes and beliefs about medication
treatment factors such as side effects
physician-related factors such as showing an authoritarian attitude toward patients
system-related factors such as treatment access problems.

Interventions that respect individual autonomy and responsibility enhance long-term adherence ( Table 2 ), whereas those that invoke fear—such as threats of hospitalization—are ineffective and demoralizing. Improved medication adherence can reduce hospitalization and health care costs.¹⁸

Table 2

Interventions to improve patient medication adherence

Issue	Intervention
Assessing medication adherence and beliefs	Specific questions (“Did you miss any doses since we last met?”) give most-accurate information Questions such as “What does taking medication mean to you?” help clarify patients’ beliefs
Dysfunctional beliefs about medication (“Taking it means I am weak.” “It can turn me into a zombie.” “I will be dependent on medication.”)	With the patient, examine evidence for dysfunctional beliefs about medication Acknowledge possible adverse effects; encourage patient to persist through mild side effects Provide objective information about the medication, including views of patients who did well on it
Lack of insight (“I do not need medication”)	Help patient identify early subjective psychotic symptoms (insomnia, restlessness, racing thoughts) Encourage patient to examine what life is like when on versus off medication Have patient ask a trusted family member or friend how he or she is different on and off medication
Forgetting to take medication	Help patient set up medication routine and stick with it Advise patient to buy an alarm clock and set it to sound when medication is to be taken Encourage patient to keep medication in a prominent place, such as at bedside Encourage him/her to use a medication organizer
Lack of a shared understanding of the illness between patient and physician	Encourage patient to state why he/she takes medication Explore patient’s understanding of the diagnosis Develop an explanation that makes sense to the patient and provides a reason to take the medication (such as, “Medication can help me achieve my goals”)

CASE: NOT REALLY HER FATHER

By the second session 1 week later, Ms. W’s suicidal thoughts had become infrequent and mild, and she was using the coping card as needed. This visit focused on visual hallucinations associated with anxiety about facing her father. We encouraged her to describe the hallucinations in great detail, and she realized that she visualized her father as he had looked 20 years ago, not as he looks today. Her anxiety decreased as she considered that she might be seeing not him but an image. Her homework assignment was to closely observe the hallucinations. Because she was more stable, the next visit was scheduled in 2 weeks.

By the third session, she reported that the visual hallucinations had disappeared, and the focusing technique had helped her. She continued to hear voices, however, particularly in the evening when she was alone and anxious or depressed. With prompting, she identified activities she could engage in at night, such as calling her mother and praying with her mother on the phone. This reduced her loneliness and helped her relax.

Table 3

Interventions to manage auditory and visual hallucinations

Problem	Intervention
Acting on hallucinations	Ask questions such as:
	“What do you say to yourself when the voices command you and you ignore them?” “What do you say to yourself when the voices command you and you follow the command?”
	Tell patient, “It is not the voices themselves but the thoughts in your mind in response to the voices that determine whether or not you follow them”
	List thoughts patient generates when choosing not to follow voice commands and encourage patient to read the list when hearing voices
Triggers of negative emotions that cause voices	Ask questions such as:
	“What kind of moods bring on the voices?” “Are the voices more likely to be triggered by anxiety, anger, frustration, or boredom?” “Can you keep track of what triggers the voices from now to the next visit?”
	Identify techniques to deal with triggers and rate their effectiveness
Dysfunctional beliefs that voices cannot be controlled or are prophetic	When voices are strong, coach patient to rate them on a scale of 0 to 10, try different distraction techniques, and rate them again
	Encourage patient to write down what the voices say and whether their prophecies come true; reviewing the record in subsequent session shows voices are not prophetic
Voices during the session	Hum a familiar tune with patient
Voices during the session	Ask patient to read out loud
Visual hallucinations	Encourage patient to examine details of what they see; this alone can make hallucinations disappear
Visual hallucinations	Encourage patient to try to make hallucinations funny, such as making the image’s nose long (personal communication: e-mail Morton Sosland MD)

One month later, the voices had diminished greatly, and Ms. W returned to her regular medication monitoring appointments of every 6 to 8 weeks.

MANAGING POSITIVE SYMPTOMS

In serious mental illnesses such as schizophrenia, the most common hallucinations are auditory ( Table 3 ),¹⁹ followed by visual and other types.²⁰ Sometimes patients view hallucinations as helpful, providing reassurance, advice, or companionship. The content may be an expression of the patient’s own beliefs.

Table 4

Interventions to help patients examine common delusions

Symptom	Questions to ask the patient
Behaviors of acting on delusions	“Let’s examine how your belief and behavior in response to it affect your life, both positive and negative” “Is this belief helping you advance in life or hindering you?” “Is this belief helping you reach your goals?”
Delusion with changing conviction	“When does this belief bother you the most?” “When does this belief bother you the least?” “How are you feeling right this minute? Is it bothering you at all?” “What is it about some situations that make you less bothered by this belief?”
Delusion with complete conviction	“When did you first have these thoughts?” “Did you believe in them right away, or did you have doubts?” “What were some of the doubts you had?” “Do you still have those doubts?”
Addressing underlying beliefs	“What does it mean to you to believe in this?” “How would life be different if you did not have this belief?”
Delusion associated with lack of real world knowledge	Provide real-world knowledge. For example, for delusion that people can read a patient’s mind, inform patient that scientific experiments have shown that no one can read complex thoughts of others
Delusion involving physician	For example, say, “It is normal for you to sometimes question my intentions and believe that I am part of the conspiracy. I can assure you that is not the case. Anytime you have those doubts I would like the opportunity to clarify those for you. Can I rely on you to bring those doubts to my attention?”
Delusion involving physician	When patient’s body language or behavior changes, ask if patient is suspicious and paranoid about you
Behavioral experiment for delusions	For example, a patient believed people parking cars on his street would break into his apartment. Homework was designed with two columns on a paper, one for him to check when someone parked and the other if they broke in. Next visit, patient returned with no checks in the break-ins column

When a patient such as Ms. W has hallucinations, consider four questions:

Are the hallucinations distressing, and does the patient want them to stop?
What triggers them (usually depressed mood, anxiety, anger, or boredom)?
What coping mechanisms has the patient used, and how effective have they been?
What is the source of the patient’s distress?

Patients may be distressed by the hallucinations’ content or by their belief that they lack control over them. When you identify negative emotions as a trigger, focus on interventions to deal with those emotions.

Table 5

Interventions for managing schizophrenia’s negative symptoms

Symptom	Intervention
Anergia/anhedonia	With the patient, list activities he thinks he can do daily Have the patient rate his pleasure and competence on a 10-point scale every time an activity is completed Tie accomplishing daily activities to patient’s long-term goals Ask a family member to encourage patient to stick to the schedule Examine automatic thoughts relating to expectations of failure
Impaired attention	Identify specific situations where attention needs to be improved Identify environmental factors that interfere with attention and encourage patient to make appropriate changes Encourage patient to read a passage in session and recap what he read; start with 2 or 3 minutes and gradually increase the duration Try loud reading if silent reading does not help
Alogia	Link effective communication to patient’s goals Make pact with patient not to answer in monosyllables Avoid yes/no questions Ask him to educate you on a topic that interests him; give positive feedback for increased speech output

Delusions tend to develop gradually, and patients initially doubt them. Even when delusions are very firm, situations can change the strength of conviction. Base interventions on logical responses to delusions ( Table 4 ) and the patient’s coping skills. Sometimes they experience delusions because they lack real-world knowledge.

Never dispute a patient’s delusional beliefs. Maintain an attitude of benevolent curiosity to elicit the reasoning processes by which he or she came to believe the delusions. By encouraging the patient to become curious about the experience, you can create a chink of insight and help the him or her achieve important goals despite disturbing sensory experiences and beliefs.

Thought disorder can be addressed by gently pointing out that you are having trouble understanding the patient’s speech. Ask if other people whom the patient trusts have commented on his or her speech.

Because thought disorder worsens the longer a patient talks, suggest a 5-sentence rule during sessions. You and the patient try to speak no more than 5 sentences at a time before pausing to let the other person speak. Encourage the patient to monitor your speech and to indicate when you violate the rule. Monitoring your speech helps patients start monitoring their own.

Thought disorder worsens when patients experience negative emotions such as anxiety. When this occurs, move the discussion to a neutral topic or encourage deep regular breathing for 2 minutes to reduce anxiety.

MANAGING NEGATIVE SYMPTOMS

Negative symptoms of schizophrenia ( Table 5 ) overlap with depression and with medication side effects. Anhedonia and social withdrawal, for example, may reflect a patient’s depression and demoralization, rather than just schizophrenia’s biological core symptoms.

Similarly, limited facial expression may be caused by drug side effects, rather than absence of affect. Negative symptoms also can occur in the absence of depression or side effects, such as when a patient’s automatic thoughts related to expectations of failure lead to lack of motivation.

Negative symptoms usually bother patients much less than positive symptoms do. Thus, enlisting family members to help patients monitor and deal with negative symptoms can be very useful.

CASE SUMMARY

Ms. W’s stress-related psychotic symptoms resolved to baseline with cognitive therapy done in a regular medication management clinic. Throughout this episode, her medication dosages remained unchanged. The interventions added about 10 minutes to sessions, effectively dealt with her symptom exacerbation, and prevented hospitalization.

Psychotropics remain a critical component of treating psychotic disorders, and psychotherapy can also be very helpful. But in the many situations when psychotherapy is not available, brief psychotherapeutic techniques can:

increase patient and family satisfaction
enhance the therapeutic alliance
improve medication adherence
promote recovery.

Adding just 5 to 10 minutes of psychotherapy to medication monitoring visits can help patients overcome hallucinations, delusions, and other psychotic symptoms. Targeted cognitive-behavioral therapy (CBT) can:

prevent crisis visits and hospitalizations
improve long-term medication and treatment adherence
enhance the therapeutic alliance.

Treatment goals for patients with chronic mental illness are changing as clinicians, patients, and families aspire for more than improved symptoms ( Box ).^1-14 This article describes brief interventions to target medication nonadherence and positive and negative symptoms in patients with schizophrenia, schizoaffective disorder, bipolar disorder, major depressive disorder, and other chronic disorders.

CASE: VOICES FROM THE PAST

Ms. W, age 45, is seen every 6 to 8 weeks in an outpatient medication management clinic for symptoms of schizoaffective disorder, depressed type; posttraumatic stress disorder; and generalized anxiety disorder. She has a history of severe abuse by her father, self-mutilation in response to anxiety and stress, and repeated hospitalizations following visits to her mother.

She recently visited her mother again and saw her father as well. The trip led to increased symptoms of intrusive traumatic memories, thoughts of suicide with plans to overdose, visual hallucinations of her father, and increased auditory hallucinations with derogatory content.

Goals of the first therapy session after Ms. W’s trip home were to reduce her suicidal thoughts and prevent hospitalization. We encouraged her to list her positive qualities, accomplishments, important relationships, religious beliefs, goals, and dreams. She then wrote all these reasons to live on a cue card. Reading the card twice in the session stopped her suicidal thoughts, and she expressed some hope.

We encouraged her to read the card whenever suicidal ideas became strong. We scheduled her next visit 1 week later, and she contracted not to attempt suicide during that time.

DEVELOPING AN ALLIANCE

To develop an alliance with psychotic patients such as Ms. W, the first task is to help them leave each session feeling understood, validated, and enjoying the therapist’s company. This alone provides a powerful counterbalance to the isolation, demoralization, and hopelessness they bring to therapy.

Box

Why drug therapy alone is not enough

Pharmacologic and psychosocial interventions are changing treatment goals for patients with serious mental illness from improved symptoms to functional recovery, improved quality of life, and reintegration into the community.^1,2 Patients, families and clinicians increasingly view self-determination, independence, and recovery as realistic treatment goals.^3,4

Medication limits. Drugs are crucial to managing psychotic symptoms but inadequate for achieving recovery:

many patients with positive psychotic symptoms respond only partially or not at all⁵
functional improvement does not always follow symptomatic improvement⁶
medication nonadherence remains high, leading to repeated relapses.⁷

Dual-therapy benefits. A combination of antipsychotics and psychotherapy has been found to increase the chances of recovery in schizophrenia.⁸ Psychotherapy is also highly valued by patients and their families:

In patient satisfaction studies, 72% to 90% of participants with psychotic disorders said individual psychotherapy improved their lives.^9,10
In a survey of 3,099 National Alliance for the Mentally Ill family members, 88% rated psychotherapy as having some (53%) or considerable (35%) value.¹¹

Access problems. Despite psychotherapy’s benefits, access is extremely limited. In one survey, only 7.3% of patients with nonaffective psychosis received at least “minimally adequate” care (four or more medication visits that did not include psychotherapy).¹² Incorporating therapeutic techniques into medication monitoring clinics is one way to improve access to therapy for patients with serious mental illnesses.

Keep it brief. Psychotherapy in medication clinics differs from traditional models’ 15- to 45-minute sessions.¹³ Patients with psychotic illness prefer brief interventions; a study of 212 patients found that 85% of those with schizophrenia preferred sessions:

less often than once a week
that focus on solving practical problems.¹⁴

Table 1

5 steps in effective cognitive-behavioral interventions

Identify the problem the patient wants to work on and narrow it down Rate the identified symptom or issue, where possible using a simple 0 to 10 rating scale Choose and use an intervention Rate the target symptom again, and get patient feedback Ask patient to write down what is learned on a card or in a notebook, and give patient an assignment to reinforce learning at home

Four principles for dealing with psychosis are normalization, universality, collaborative therapeutic alliance, and focusing on the patient’s life goals:

In normalization, the stress vulnerability model is used to explain psychosis to the patient. Psychotic symptoms are emphasized as something normal people can experience in extreme situations, such as:

hallucinations in states of sleep deprivation or medical and drug-induced states
paranoia as error in thinking in states of heightened vigilance and perceived threat.¹⁵

Universality is the understanding that many people have experiences similar to the patient’s.

In a collaborative therapeutic alliance, the patient is not a passive recipient but an active collaborator in therapy. He or she contributes to decisions—such as the length of therapy and topics to be discussed—and gives feedback on interventions and therapist style.

Focusing on life goals makes therapy meaningful to the patient.

Set priorities. Because only one or two therapeutic interventions can be tried during a medication-monitoring visit, problems need to be prioritized. As with Ms. W, the first visit’s goal was crisis intervention: to reduce suicidal thoughts and prevent hospitalization. Table 1 offers a framework for effective therapeutic interventions.

Save time by giving patients out-of-session assignments, which:

collect important information to review with patients during the next monitoring session
help empower patients to manage their symptoms.

Adaptive strategies—such as drill and practice¹⁷—can help improve learning in patients with cognitive impairment, which is common in psychotic disorders.¹⁶ Give the patient a pocket notebook to write down what he learns in sessions, and encourage him to review the material at home. Call this a book of coping skills.

IMPROVING ADHERENCE

Medication nonadherence and partial adherence can result from:

illness-related factors such as lack of insight
patient-related factors such as attitudes and beliefs about medication
treatment factors such as side effects
physician-related factors such as showing an authoritarian attitude toward patients
system-related factors such as treatment access problems.

Interventions that respect individual autonomy and responsibility enhance long-term adherence ( Table 2 ), whereas those that invoke fear—such as threats of hospitalization—are ineffective and demoralizing. Improved medication adherence can reduce hospitalization and health care costs.¹⁸

Table 2

Interventions to improve patient medication adherence

Issue	Intervention
Assessing medication adherence and beliefs	Specific questions (“Did you miss any doses since we last met?”) give most-accurate information Questions such as “What does taking medication mean to you?” help clarify patients’ beliefs
Dysfunctional beliefs about medication (“Taking it means I am weak.” “It can turn me into a zombie.” “I will be dependent on medication.”)	With the patient, examine evidence for dysfunctional beliefs about medication Acknowledge possible adverse effects; encourage patient to persist through mild side effects Provide objective information about the medication, including views of patients who did well on it
Lack of insight (“I do not need medication”)	Help patient identify early subjective psychotic symptoms (insomnia, restlessness, racing thoughts) Encourage patient to examine what life is like when on versus off medication Have patient ask a trusted family member or friend how he or she is different on and off medication
Forgetting to take medication	Help patient set up medication routine and stick with it Advise patient to buy an alarm clock and set it to sound when medication is to be taken Encourage patient to keep medication in a prominent place, such as at bedside Encourage him/her to use a medication organizer
Lack of a shared understanding of the illness between patient and physician	Encourage patient to state why he/she takes medication Explore patient’s understanding of the diagnosis Develop an explanation that makes sense to the patient and provides a reason to take the medication (such as, “Medication can help me achieve my goals”)

CASE: NOT REALLY HER FATHER

By the second session 1 week later, Ms. W’s suicidal thoughts had become infrequent and mild, and she was using the coping card as needed. This visit focused on visual hallucinations associated with anxiety about facing her father. We encouraged her to describe the hallucinations in great detail, and she realized that she visualized her father as he had looked 20 years ago, not as he looks today. Her anxiety decreased as she considered that she might be seeing not him but an image. Her homework assignment was to closely observe the hallucinations. Because she was more stable, the next visit was scheduled in 2 weeks.

By the third session, she reported that the visual hallucinations had disappeared, and the focusing technique had helped her. She continued to hear voices, however, particularly in the evening when she was alone and anxious or depressed. With prompting, she identified activities she could engage in at night, such as calling her mother and praying with her mother on the phone. This reduced her loneliness and helped her relax.

Table 3

Interventions to manage auditory and visual hallucinations

Problem	Intervention
Acting on hallucinations	Ask questions such as:
	“What do you say to yourself when the voices command you and you ignore them?” “What do you say to yourself when the voices command you and you follow the command?”
	Tell patient, “It is not the voices themselves but the thoughts in your mind in response to the voices that determine whether or not you follow them”
	List thoughts patient generates when choosing not to follow voice commands and encourage patient to read the list when hearing voices
Triggers of negative emotions that cause voices	Ask questions such as:
	“What kind of moods bring on the voices?” “Are the voices more likely to be triggered by anxiety, anger, frustration, or boredom?” “Can you keep track of what triggers the voices from now to the next visit?”
	Identify techniques to deal with triggers and rate their effectiveness
Dysfunctional beliefs that voices cannot be controlled or are prophetic	When voices are strong, coach patient to rate them on a scale of 0 to 10, try different distraction techniques, and rate them again
	Encourage patient to write down what the voices say and whether their prophecies come true; reviewing the record in subsequent session shows voices are not prophetic
Voices during the session	Hum a familiar tune with patient
Voices during the session	Ask patient to read out loud
Visual hallucinations	Encourage patient to examine details of what they see; this alone can make hallucinations disappear
Visual hallucinations	Encourage patient to try to make hallucinations funny, such as making the image’s nose long (personal communication: e-mail Morton Sosland MD)

One month later, the voices had diminished greatly, and Ms. W returned to her regular medication monitoring appointments of every 6 to 8 weeks.

MANAGING POSITIVE SYMPTOMS

In serious mental illnesses such as schizophrenia, the most common hallucinations are auditory ( Table 3 ),¹⁹ followed by visual and other types.²⁰ Sometimes patients view hallucinations as helpful, providing reassurance, advice, or companionship. The content may be an expression of the patient’s own beliefs.

Table 4

Interventions to help patients examine common delusions

Symptom	Questions to ask the patient
Behaviors of acting on delusions	“Let’s examine how your belief and behavior in response to it affect your life, both positive and negative” “Is this belief helping you advance in life or hindering you?” “Is this belief helping you reach your goals?”
Delusion with changing conviction	“When does this belief bother you the most?” “When does this belief bother you the least?” “How are you feeling right this minute? Is it bothering you at all?” “What is it about some situations that make you less bothered by this belief?”
Delusion with complete conviction	“When did you first have these thoughts?” “Did you believe in them right away, or did you have doubts?” “What were some of the doubts you had?” “Do you still have those doubts?”
Addressing underlying beliefs	“What does it mean to you to believe in this?” “How would life be different if you did not have this belief?”
Delusion associated with lack of real world knowledge	Provide real-world knowledge. For example, for delusion that people can read a patient’s mind, inform patient that scientific experiments have shown that no one can read complex thoughts of others
Delusion involving physician	For example, say, “It is normal for you to sometimes question my intentions and believe that I am part of the conspiracy. I can assure you that is not the case. Anytime you have those doubts I would like the opportunity to clarify those for you. Can I rely on you to bring those doubts to my attention?”
Delusion involving physician	When patient’s body language or behavior changes, ask if patient is suspicious and paranoid about you
Behavioral experiment for delusions	For example, a patient believed people parking cars on his street would break into his apartment. Homework was designed with two columns on a paper, one for him to check when someone parked and the other if they broke in. Next visit, patient returned with no checks in the break-ins column

When a patient such as Ms. W has hallucinations, consider four questions:

Are the hallucinations distressing, and does the patient want them to stop?
What triggers them (usually depressed mood, anxiety, anger, or boredom)?
What coping mechanisms has the patient used, and how effective have they been?
What is the source of the patient’s distress?

Patients may be distressed by the hallucinations’ content or by their belief that they lack control over them. When you identify negative emotions as a trigger, focus on interventions to deal with those emotions.

Table 5

Interventions for managing schizophrenia’s negative symptoms

Symptom	Intervention
Anergia/anhedonia	With the patient, list activities he thinks he can do daily Have the patient rate his pleasure and competence on a 10-point scale every time an activity is completed Tie accomplishing daily activities to patient’s long-term goals Ask a family member to encourage patient to stick to the schedule Examine automatic thoughts relating to expectations of failure
Impaired attention	Identify specific situations where attention needs to be improved Identify environmental factors that interfere with attention and encourage patient to make appropriate changes Encourage patient to read a passage in session and recap what he read; start with 2 or 3 minutes and gradually increase the duration Try loud reading if silent reading does not help
Alogia	Link effective communication to patient’s goals Make pact with patient not to answer in monosyllables Avoid yes/no questions Ask him to educate you on a topic that interests him; give positive feedback for increased speech output

Delusions tend to develop gradually, and patients initially doubt them. Even when delusions are very firm, situations can change the strength of conviction. Base interventions on logical responses to delusions ( Table 4 ) and the patient’s coping skills. Sometimes they experience delusions because they lack real-world knowledge.

Never dispute a patient’s delusional beliefs. Maintain an attitude of benevolent curiosity to elicit the reasoning processes by which he or she came to believe the delusions. By encouraging the patient to become curious about the experience, you can create a chink of insight and help the him or her achieve important goals despite disturbing sensory experiences and beliefs.

Thought disorder can be addressed by gently pointing out that you are having trouble understanding the patient’s speech. Ask if other people whom the patient trusts have commented on his or her speech.

Because thought disorder worsens the longer a patient talks, suggest a 5-sentence rule during sessions. You and the patient try to speak no more than 5 sentences at a time before pausing to let the other person speak. Encourage the patient to monitor your speech and to indicate when you violate the rule. Monitoring your speech helps patients start monitoring their own.

Thought disorder worsens when patients experience negative emotions such as anxiety. When this occurs, move the discussion to a neutral topic or encourage deep regular breathing for 2 minutes to reduce anxiety.

MANAGING NEGATIVE SYMPTOMS

Negative symptoms of schizophrenia ( Table 5 ) overlap with depression and with medication side effects. Anhedonia and social withdrawal, for example, may reflect a patient’s depression and demoralization, rather than just schizophrenia’s biological core symptoms.

Similarly, limited facial expression may be caused by drug side effects, rather than absence of affect. Negative symptoms also can occur in the absence of depression or side effects, such as when a patient’s automatic thoughts related to expectations of failure lead to lack of motivation.

Negative symptoms usually bother patients much less than positive symptoms do. Thus, enlisting family members to help patients monitor and deal with negative symptoms can be very useful.

CASE SUMMARY

Ms. W’s stress-related psychotic symptoms resolved to baseline with cognitive therapy done in a regular medication management clinic. Throughout this episode, her medication dosages remained unchanged. The interventions added about 10 minutes to sessions, effectively dealt with her symptom exacerbation, and prevented hospitalization.

Psychotropics remain a critical component of treating psychotic disorders, and psychotherapy can also be very helpful. But in the many situations when psychotherapy is not available, brief psychotherapeutic techniques can:

increase patient and family satisfaction
enhance the therapeutic alliance
improve medication adherence
promote recovery.