The NAVIGATE Program for First-Episode Psychosis: Rationale, Overview, and Description of Psychosocial Components
Abstract
Treatment Programs for First-Episode Psychosis
The NAVIGATE Program
Target Population and Setting
The NAVIGATE Treatment Team
NAVIGATE Team-Based Activities
Treatment Planning, Review, and Discharge
NAVIGATE Manuals
Conceptual Foundations of the NAVIGATE Program
Core Skills of NAVIGATE Team Members
Skill area and goals | Key elements |
---|---|
Shared decision-making skills | |
Facilitate active engagement in treatment | Information provided about treatment options and likely consequences |
Establish and maintain good working alliance between client and team members | Client preferences elicited and respected |
Support self-determination and personal autonomy | Treatment decisions negotiated and made jointly; family members involved (with client permission) |
Strengths and resiliency focus | |
Improve positive feelings and self-esteem | Identify personal qualities, knowledge, skills, and resources |
Instill hope for the future | Draw attention to strengths and consider how to capitalize on them to achieve goals |
Promote use of all available resources for achieving goals | Explore how person coped with and bounced back from previous challenges |
Help person move forward in life after disruption of psychotic episode and any persistent difficulties | Build upon and enhance skills for dealing with stress and rebounding from setbacks |
Motivational enhancement | |
Increase effort to work on personal goals | Empathic listening |
Enhance desire to improve illness management | Elicit goals and support self-efficacy for achieving them |
Resolve ambivalence about behavior change | Explore how improved illness management could help achieve goals |
Help find a sense of purpose in one’s life | Instill hope for achieving goals |
Psychoeducational skills | |
Provide important information to enable shared decision making | Provide information in different formats (for example, handouts, discussion, and whiteboard) |
Ensure relevant information is understood and retained | Break up information into small “chunks” |
Facilitate ability to access and use information when needed | Interactive teaching and discussion format, with frequent breaks to ask and answer questions, check understanding, and explore person’s experience |
Help individual learn practical facts about illness and its treatment | Adapt language, special terms (for example, diagnosis), and amount of detail to the individual; seek common ground when there are disagreements about topics such as symptoms and diagnosis |
Collaboration with natural supports | |
Enlist family support for client goals and participating in treatment; improve monitoring of client’s disorder; and reduce stress in the family | Broad definition of “family” based on client’s wishes; outreach to engage family members; provide information to family about illness and treatment similar to that in the standard work on IRT; elicit and respond to family members’ questions and concerns; avoid judgment; express empathy about challenging experiences and focus on resiliency; ensure that treatment team members are accessible to family; responsive to family requests for help |
Shared Decision Making
Strengths and Resiliency Focus
Motivational Enhancement Skills
Psychoeducational Skills
Collaboration With Natural Supports
Treatment Interventions Provided in the NAVIGATE Program
Intervention | Provider | Goals | Description |
---|---|---|---|
Individualized medication management | Prescriber | Reduce symptoms; minimize side effects and adverse medical health outcomes | Provided to all clients; regular monitoring of symptoms, treatment adherence, and side effects by using standardized questions during regular office visits; continuous monitoring of risk factors for metabolic and cardiovascular disease; guideline-based pharmacological treatment emphasizing low doses; close coordination with primary care provider and referral for medical services, when appropriate; encourage healthy lifestyles, which can include coordination with the IRT clinician on lifestyle changes |
Family education program | Director (typically) | Establish collaborative relationships between family and treatment team; instill hope for recovery from psychosis; teach family about psychosis and its treatment; strengthen communication; reduce family stress; improve family support for client’s goals and participation in treatment; prevent relapses | Offered to all families, with client consent; holding an individual session with each significant other and the client to get to know them, hear their experience, and get their point of view; family education (10–12 sessions; offered to all families; education about psychosis, treatment, and stress reduction; development of relapse prevention plan; emphasis on family resiliency and strengths); monthly check-ins (brief monthly in-person or phone contact to review progress and identify family concerns or clinical issues; conducted following completion of family education); family consultation (1 or 2 sessions per problem as needed; addresses specific problem identified by family; focused problem-solving approach used by family clinician; specific solutions identified, action plan formulated, and follow-up conducted); modified intensive skills training (8–12 sessions if needed after basic family education completed; targets persistently high levels of family stress; intensive skills-training methods used to teach communication and problem-solving skills) |
Individual resiliency training (IRT) | IRT clinician | Help client achieve personal recovery goals; educate about psychosis and its treatment; process experience of the psychotic episode; improve illness self-management, including relapse prevention and coping; reduce substance abuse; increase social support and quality of relationships; increase resiliency and well-being; improve health | Psychotherapeutic interventions based on cognitive-behavioral therapy and motivational interviewing offered to all clients; individual sessions conducted weekly or biweekly for as long as needed; goal setting and tracking throughout the program; educational and skills curriculum organized into different topic areas (or modules), with handouts and clinician guides for each module; standard modules recommended for all clients; individualized modules provided as needed or when desired; flexibility in which modules to cover, when, and in what depth; information, strategies, and skills taught using motivational, psychoeducational, and cognitive-behavioral methods; home assignments collaboratively set and followed up each session |
Supported employment and education (SEE) | SEE specialist | Obtain and keep competitive employment; enroll in mainstream education programs and obtain desired degrees | Offered to all clients; specific work and school goals developed based on client’s preferences; prevocational training not required; rapid job or school search following identification of client’s goals; most services provided in the community not the clinic; practical assistance in finding jobs or enrolling in school programs, including interacting with employers or school personnel; respect for client’s decision about disclosure of psychiatric disorder to employers or school personnel; follow-along supports after client gets a job or enrolls in school in order to facilitate job retention, school degree completion, or transition to another job or school |
Individualized Medication Treatment
Family Education Program
Individual Resiliency Training
Module | Description | N of sessions |
---|---|---|
Standard module | ||
Orientation | Overview of IRT program, providing treatment expectations, description of all modules, and teaching and practice of breathing-retraining skill for anxiety reduction | 1 or 2 |
Assessment and goal setting | Evaluation and discussion of clients’ character strengths and areas of life satisfaction and dissatisfaction in order to create specific short- and long-term personally meaningful goals | 2–4 |
Education about psychosis | Didactics and discussion about the stress-vulnerability model and various aspects of psychosis, including dispelling myths to destigmatize mental illness | 7–11 |
Relapse prevention planning | Discussion of triggers and warning signs and development of personalized plan for preventing relapse and rehospitalization | 2–4 |
Processing the psychotic episode | Development of cohesive narrative of episode, narrative exposure-based processing of traumatic reactions, and targeted cognitive restructuring for self-stigmatizing beliefs | 3–5 |
Developing resiliency | Positive psychology exercises to enhance resilient qualities, increase positive emotions, and build skills for using particular strengths in daily life | 3 or 4 |
Building a bridge to your goals | Progress and goal review, discussion of possible use of individualized modules with plan for continuation or termination | 2 or 3 |
Individualized module | ||
Dealing with negative feelings | Cognitive restructuring for coping with psychotic, posttraumatic, mood, and anxiety symptoms | 7–12 |
Coping with symptoms | Behavioral coping strategy enhancement for psychotic symptoms, mood, and anxiety symptoms | 2 per symptom |
Substance use | Assessment of substance use and interference of substances combined with motivational interviewing approach to develop cognitive and behavioral strategies to reduce substance use | 11–20 |
Having fun and developing good relationships | Based on social skills training to increase pleasurable activities and adaptive interpersonal communications | 3–27 |
Making choices about smoking | Motivational interviewing approach coupled with behavioral and cognitive coping strategies to help with decision making and next steps about smoking cessation | 2–4 |
Nutrition and exercise | Education about weight gain and psychosis, including metabolic syndrome, plus behavioral strategies for improving general medical health | 2–4 |
Supported Employment and Education
Conclusions
Acknowledgments
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