Although the absolute risk of violence among persons with psychosis is low, young adults experiencing early psychosis are at higher risk of violent behavior than the general population. Studies have shown that intensive treatment in the first two years can help mitigate downstream consequences related to psychosis and that cognitive behavioral therapy (CBT)‐based psychotherapy can reduce impairment and improve function in these patients. However, no studies have explored using CBT-based interventions to reduce violence among adults with early psychosis in specialized early intervention services settings.
Below, Stephanie Rolin, MD, MPH, a forensic psychiatrist at NewYork-Presbyterian and Columbia, discusses the findings from her recent study looking at the acceptability and feasibility of a behavioral intervention to reduce violence among young adults with early psychosis.
Research Methods
For this study, I analyzed the Psychological Intervention for Complex PTSD and Schizophrenia-Spectrum Disorder (PICASSO) model, a CBT approach for psychosis that has been modified to target anger and violence. I developed a qualitative interview guide to speak with patients at OnTrackNY who had had an episode of violent ideation or behavior in the past six months. I chose to include violent ideation in hopes of creating a proactive intervention. I also created an interview guide to speak with clinicians and peer specialists who were employed at OnTrackNY and had experience working with participants who had a history of violence.
For the first part of the interview guide, I used the cultural formulation interview developed by Columbia psychiatrist Roberto Lewis-Fernández, MD, to understand the participants’ identities and experiences with violence and trauma. I included this interview because I think our understanding of violence and trauma is so individualized that it's essential to understand the lens that we each bring when speaking about it.
In the second part of the interview, I developed a violence narrative. For this component, I worked with Barbara Stanley, PhD, a former researcher at Columbia who pioneered and developed suicide narratives, to try and identify opportunities for intervention.
In the third part of the interview, I described the PICASSO intervention and asked people for their input and feedback. For the patients, I asked, “would you want to do this? Why or why not? Who in your life would support you in doing this? What would you hope to gain?” For peer specialists and clinicians, I asked, “would you want to offer treatment like this? What might make it hard to use? What kind of support might they need? How can we adapt and change the intervention to make it better suited to the needs of young people with early psychosis and better suited to what clinical teams are looking for?”
What I heard from patients was devastating; even a single violent incident had devastating consequences on their life, including police charges, jail, loss of housing and jobs, or needing to leave school.
— Dr. Stephanie Rolin
Key Findings
One of the things that was remarkable in speaking to young people with early psychosis and their treatment teams was how able they were to talk about violence. Despite the stigma, they could reflect on what's happened and share how it's affected their lives. What I heard from patients was devastating; even a single violent incident had devastating consequences on their life, including police charges, jail, loss of housing and jobs, or needing to leave school.
Overall, I found that patients, peer specialists, and clinicians wanted proactive, preventative treatments for violent behavior. Most people felt that the current way violence is handled in patients with early psychosis is too reactive, where we wait until something happens and then respond after the fact. Often, this can lead to hospitalization and mandated treatment, limiting people's choices. I heard from clinical teams that they want to be able to offer help before something violent occurs. The feedback about a preventative and voluntary intervention like this was positive.
Future Directions
I am running a small, open pilot clinical trial of the adapted PICASSO intervention, which consists of 12 sessions of outpatient CBT. The treatment focuses on identifying an individual's goals and aligning these with individualized CBT strategies to help them achieve them. I have enrolled several clinicians and patients who are testing this treatment to see whether it's feasible, acceptable, and potentially effective. I’m expecting to include 10-16 participants in this phase. From there, I'll further adapt the manual, and I plan to run a larger pilot randomized control trial later in this grant.
