Developing a mechanism-based therapy for acute psychiatric inpatients with psychotic symptoms: an Intervention Mapping approach

Abstract

Background: Treatment guidelines for psychosis recommend offering psychotherapy already in the acute illness phase. However, there is a lack of available interventions adapted to the specific needs and key change mechanisms of inpatients experiencing severe symptoms and crisis. In this article we outline the scientific development process of a needs-oriented and mechanism-based group intervention for acute psychiatric inpatients with psychosis (MEBASp).

Methods: To guide our intervention design, we used Intervention Mapping (IM), a six-step framework for developing evidence-based health interventions that consisted of an extensive literature review, an in-depth problem definition and needs analysis, the modeling of change mechanisms and outcomes and the production of an intervention prototype.

Results: Our low-threshold modularized group intervention consists of nine stand-alone sessions (two per week) within three modules and targets different aspects of metacognitive and social change mechanisms. Module I and II aim to reduce acute symptoms by fostering cognitive insight, Module III focuses on reducing distress via cognitive defusion. Therapy contents are adapted from existing metacognitive treatments such as the Metacognitive Training and presented in a destigmatizing, simply understandable and experience-oriented way.

Conclusion: MEBASp is currently evaluated in a single-arm feasibility trial. Using a systematic and rigorous development methodology and providing a detailed description of the development steps demonstrated to be invaluable in improving the intervention's scientific foundation, validity, and replicability for similar research.

Keywords: acute inpatients; group therapy; intervention development; intervention mapping; mechanism-based; metacognition; psychosis.

FIGURE 1

Illustration of the IM intervention development process and selected steps undertaken in the MEBASp project.

FIGURE 2

Logical model of the problem of severe psychotic symptoms, danger to self and others, (involuntary) hospitalization and a resulting low quality of life (Step 1). The model has a focus on psychological and social factors in the development of psychosis and does not consider biological factors e.g., genetics. It moreover does not map the moderating or mediating relationships between variables, but rather aims to visualize the variability of factors and impaired processes that contribute to these main health problems (40). Impaired processes that were identified as target areas for the logical model of change are underlined.

FIGURE 3

Logical model of change showing what change is needed to manage the main health problems of severe psychotic symptoms and danger to self and others (Step 2). It points out the change domains and belonging change mechanisms expected to influence the cognitive, behavioral and environmental outcomes that are in turn believed to improve mental health and quality of life. Hypothesized underlying target change mechanisms are put into square brackets.

FIGURE 4

Example slides from each module. Top left: Slide from the module “Psychoeducation”. Patients learn to understand that different thoughts can lead to different feelings and behaviors (slight adapted from the MCT manual for depression) (72) (p. 105). Top right: Slide from the module “Cognitive Insight” and session “To empathize”. Patients learn to understand that facial expressions can easily be misinterpreted (slide used from the MCT-acute concept, open source on the MCT website, https://clinical-neuropsychology.de/metacognitive_training/). Bottom left: Slide from the module “Cognitive Defusion” and session “Helpful vs. unhelpful thoughts”. Patients learn to distinguish between helpful and unhelpful internal experiences. Bottom right: Slide from the module “Cognitive Defusion” and session “Defusion techniques”. Patients learn to notice and name thoughts in order to create distance to them instead of getting entangled in thought contents and automatic reactions.