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RESEARCH PRODUCT

The Need-Adapted Approach in Psychosis: The Impact of Psychosis on the Treatment and the Professionals

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Psychosis is a challenging phenomenon for professionals. In the need-adapted approach (NAA), therapy meetings constitute a deliberate effort to meet the challenges by bringing all the main parties together within a common discussion. The aims of this study are to analyze and evaluate psychiatrists' experiences of the treatment processes in psychosis. A qualitative multiple case study approach has been used. Between August 2007 and January 2009, co-research interviews (CR-Is) and stimulated-recall interviews (STR-Is) with 10 psychiatrists from 3 different parts of Finland were videoed and transcribed verbatim. The material was analyzed using qualitative content analysis. The difficult emotions of the professionals and the critical views expressed had a prominent role. It was almost impossible to proceed with the treatment until the memories of coercive acts had been addressed. There were fewer harmful effects in outpatient than in inpatient care. If the client-centered principles of NAA were not followed, the CR-Is functioned primarily as critical evaluations of the treatment processes. The STR-Is helped the psychiatrists to find words for difficult experiences. For the sake of both practice and research, the experiences of staff in the treatment of psychosis should be taken into account. For better prediction of failure, routine measures to obtain feedback could be included in NAA.Keywords: psychosis; need-adapted treatment; psychiatrists' experiences; qualitative studyPsychotic crises are distressing to patients and to their social network. They also constitute a challenge to professionals, not least to psychiatrists. The needadapted approach (NAA; Alanen, 2009) incorporates an effort to bring the patient, his or her social network, and all relevant professionals together to meet the challenges that occur. In NAA the psychiatrist works as part of a team, and aspects of treatment are discussed and decided on together with patients, family members, and staff during therapy meetings (Rakkolainen, Lehtinen, & Alanen, 1991). The meet-ings are guided by a psychotherapeutic attitude to find a common understanding of what has happened and an evaluation of the real and changing needs of the patients and the family. Concrete treatment plans are drawn up and continuously revised within therapy meetings. The purpose is to work with the experiences of the clients and to avoid the dominance of a medical perspective which could result in unneces-sary treatments.For several years, two of the writers have worked in psychosis teams as family therapy professionals (the first author [PB] having trained as a psychiatrist and the second author [JS] as a clinical psychologist). While following NAA procedures, we have observed many challenges associated with specific features of the psychosis phenomenon. Professionals find certain aspects of psychosis confusing and even threatening. They have to deal with the patient's loss of a sense of reality, incoherent psychological boundaries separating the self from others, gaps and shifts in associations, and the substitution of an organized and realistic logic by a more archaic logic of dreams-all this together with a weakening of impulse control because of delusions, hallucinations, and affective disorders (Alanen, 1997). This often leads to difficulties in treatment collaboration. Frequently, the professionals feel obliged to get the patients to admit their illness and to take medication to control their psychotic symptoms. The patients- who arrive upset, suspicious, and frightened in the first place-are left alone with their frightening experiences or even exposed to trauma, in the case of i nvoluntary treatment.Democratic societies deal with psychosis very differently from most other health problems. Although there are differences in Europe in both legislation and clinical practices regarding the compulsory treatment of psychotic patients (Jacobsen, 2012), psychiatrists and other professionals have exceptional power and responsibility in the processes concerned. …