Schizophrenia and Post-Psychotic Adjustment

Q&A

We are pleased to present this Q&A with Mary D. Moller, DNP, APRN, PNHCNS-BC, CPRP, FAAN, Associate Professor at Pacific Lutheran University in Tacoma, Washington, where she is Director of the Undergraduate Psychiatric Nursing (PMH) Program. There, Dr Moller is developing a PMH-Doctor of Nursing Practice program. Before her appointment at PLU, she was Director of the Psychiatric-Mental Health Nurse Practitioner specialty at Yale University School of Nursing, in New Haven, Connecticut.

Q: Your presentation at PsychCongress is titled “From the Couch, to the Bus Depot, to the Mall, to Work: Understanding the Relationship of Post-Psychotic Adjustment to Recovery in Schizophrenia.” Can you tell us about this?

A: It wasn’t all that long ago in the history of treating psychoses, that patients weren’t even informed of their diagnosis, let alone have anything explained to them about what that diagnosis meant or how it was treated. Patients were often not included as equal partners in care.

Articulating the components of comprehensive adjustment to life after having had a psychotic episode and diagnosis of schizophrenia is new. The concept was developed during my doctoral program at Case Western Reserve University in 2006. The post-psychotic adjustment process is described in the Milestones of Recovery Post-Psychotic Recovery Model (MAPP). MAPP defines a non-linear, 4-phase process (cognitive dissonance, insight, cognitive constancy, and ordinariness), based on Festinger’s Cognitive Dissonance theory includes cognitive, emotional, interpersonal, and physiological milestones within each phase.

The entire process lasts a minimum of 2 years to complete. The MAPP provides a recovery trajectory that providers can use to identify where and why individual’s get “stuck” in moving forward to achieving life goals. Through use of the MAPP, providers can truly individualize treatment for schizophrenia and other psychoses.

Q: Why did you select this topic?

A: In 2003 I conducted focus groups with patients regarding difficulty moving forward with life after seemingly reaching a good level of symptom control with medications and therapy. I was developing a tool called the Impact of Psychosis Questionnaire. There was one open-ended narrative written by a 24-year-old man that forever changed the way I looked at treatment. He wrote, “Mary, how would you like to know you went so crazy that your parents had to call the cops and they came to our neighborhood with sirens blaring, the rescue squad, and a fire truck. They came into our house and handcuffed me and drug me out to the police car and threw me in and hauled me to a psych ward where they drugged me up and sent me home after a while. How was I supposed to put my shoes on and ever go out my front door again knowing what my neighbors had seen?”

After I read that, I started to cry and thought to myself, “I’ve never thought about treatment or recovery like that. I’ve always been the cheerleader and encouraged patients to jump right back into life. I had never stopped to think about what it was really like at that deeply introspective level.” I realized then I needed to study this aspect of care, and that is what prompted me to get my doctorate.

Q: What areas will the workshop cover?

A: I will go over the 4 phases of the MAPP and will outline the treatment milestones occurring within each phase. I will also include patient narratives that explicate the milestones, as well as needed psychiatric service system changes based on the MAPP.

The MAPP will help pinpoint cognitive, emotional, interpersonal, and physiological aspects of why patients have a hard time with adherence. These milestones can serve as a basis for motivational interviewing techniques.

Dr Moller’s presentation at PsychCongress took place on Sunday, September 21, from 10:15 to 11:45 AM.

Suggested reading:
Moller MD, Zauszniewsky JA. Psychophenomenology of the post-psychotic adjustment process. Arch Psychiatr Nurs. 2011;25:253-268.

Moller MD. Neurobiological responses and schizophrenia and other psychotic disorders. In: Stuart G, ed Principles and Practices of Psychiatric Nursing, 10th Ed. St. Louis, Missouri: Mosby; 2012.

Cavelti M, Beck, EM, Kvrgic S, et al. The role of subjective illness beliefs and attitude toward recovery within the relationship of insight and depressive symptoms among people with schizophrenia spectrum disorders. J Clin Psychol. 2012;68:462-476.

Lysaker PH, Ringer J, Maxwell C, et al. Personal narratives and recovery from schizophrenia. Schizophr Res. 2011;121:271-276.

Lysaker PH, Lysaker JT. Schizophrenia and alterations in self-experience: A comparison of 6 perspectives. Schizophr Bull. 2010;36:331-340