A Nursing Tool for Insight
and Adherence in Psychosis
Promoting Insight and Enhancing Recovery
Sharon Sousa, Ed.D.,R.N.,C.S.
College of Nursing
University of Massachusetts Dartmouth
A Nursing Tool for Insight
and Adherence in Psychosis

Poor insight makes successful
collaborations in treatment more
difficult and is an exceptionally
troubling impediment to improvement
A Nursing Tool for Insight
and Adherence in Psychosis


Increasing adherence and insight
may enhance the potential for
recovery
At present, there are few costeffective strategies to improve
insight in psychosis
A Nursing Tool for Insight
and Adherence in Psychosis


We developed the Levels of
Recovery from Psychotic Illnesses
Scale (LORS) as a teaching tool for
patients with psychotic illnesses to
enhance insight & adherence
The LORS was also developed for
educating families and clinicians
LORS
Levels of Recovery from Psychotic Disorders
NAME:
DATE:

ACTIVE ILLNESS
(DANGER TO SELF & OTHERS)
ACTIVE ILLNESS
(CONTROLLED PSYCHOSIS)
HOSPITAL WARD
STABLE BUT NOT IMPROVING
CUSTODIAL CARE
COMMUNITY RESIDENCE
STAFFED
SUPERVISION
locked ward
 24 hour nursing care

POTENTIAL FOR VIOLENCE
POTENTIAL FOR VIOLENCE

POSITIVE
SYMPTOMS OF
ILLNESS

very high risk
VOICES
 present most of the time,
occasional command
hallucinations
THINKING
VOICES
 present much of the time,
significantly affect
functioning
VOICES
 present much of the time,
sometimes able to ignore
THINKING
THINKING
POTENTIAL FOR VIOLENCE

VOICES
 less intrusive, viewed as
part of illness
THINKING
very insignificant
VOICES
 none or minimal
THINKING
clear, organized
KNOWLEDGE REGARDING
ILLNESS & ADHERENCE
TO TREATMENT
 poor & questionable
adherence
KNOWLEDGE REGARDING
ILLNESS & ADHERENCE
TO TREATMENT
 fair - some denial
KNOWLEDGE REGARDING
ILLNESS & ADHERENCE
TO TREATMENT
 fair - minimal denial
KNOWLEDGE REGARDING
ILLNESS & ADHERENCE
TO TREATMENT
 good
FACIAL EXPRESSION
somewhat distressed,
anxious or flat
FACIAL EXPRESSION
demonstrates spontaneous
humor
FACIAL EXPRESSION
 adequate range of
expression
FACIAL EXPRESSION
very distressed, anxious
or flat
REALITY TESTING
fair

more organized, unpleasant
minor risk
KNOWLEDGE REGARDING
ILLNESS & ADHERENCE
TO TREATMENT
 poor & complete denial

less bizarre, unpleasant
POTENTIAL FOR VIOLENCE

REALITY TESTING
more reality based


REALITY TESTING
good



FACIAL EXPRESSION
 less distressed, anxious

SPEECH
monotonous voice

SPEECH
initiates some conversation

SPEECH
better tone, volume

SPEECH
give-and-take dialogue

INTEREST IN OTHERS
does not initiate relationships

INTEREST IN OTHERS
shows interets in others

INTEREST IN OTHERS
cooperates with others

INTEREST IN OTHERS
avoids close relationships
VOLUNTEER OR WORK
very limited
concentration for tasks poor
 housekeeping room minimal

VOLUNTEER OR WORK
more time with tasks
improved concentration
 housekeeping own area
VOLUNTEER OR WORK
day treatment program
psychosocial rehab program
 sheltered employment
VOLUNTEER OR WORK
TEP (1/2 time/clubhouse)
supported education
 job training








PERSONAL HYGIENE CARE

poor
SOCIAL INTERACTION SKILLS
 very poor
ADVOCACY
moderate risk


SOCIAL SKILLS
POTENTIAL FOR VIOLENCE



WORK &
EDUCATION
high risk
INDEPENDENT LIVING
independent home
 flexible support from staff


REALITY TESTING
poor
NEGATIVE
SYMPTOMS OF
ILLNESS

rehabilitation house
 3/4, 1/2, 1/4 house

NORMALIZED ACTIVITY
goal directed, pleasant,
occasional problems
REALITY TESTING
 reality based most of time

bizarre, unpleasant
unlocked ward
 day hospital
 partial hospital
STABLE & IMPROVING
STAFFED SUPPORTED
APARTMENT
 includes other's home
INITIATES SELF ADVOCACY
no self advocacy for needs
no future orientation to
goals
PERSONAL HYGIENE CARE

grooming, hygiene requires
staff encouragement
SOCIAL INTERACTION SKILLS
 eye contact, body language
poor
INITIATES SELF ADVOCACY
limited self advocacy
limited future orientation to
goals




PERSONAL HYGIENE CARE

limited interest in grooming
SOCIAL INTERACTION SKILLS
 improved eye contact,
smiling, better non-verbal
communication
INITIATES SELF ADVOCACY
increasingly voicing own
desires
 more future goal orientation

PERSONAL HYGIENE CARE

adequate attention to
grooming
SOCIAL INTERACTION SKILLS
 good
INITIATES SELF ADVOCACY
improved sense of self
goals present & future
focused


SPEECH
good conversations
INTEREST IN OTHERS
enjoys relationships with
others
VOLUNTEER OR WORK
independent employment
P/T or F/T
 independent education
 independent voluntier

PERSONAL HYGIENE CARE

enjoys good personal
presentation
SOCIAL INTERACTION SKILLS
 involved in normal social
interaction
INITIATES SELF ADVOCACY
plans and executes long
term goals

Copyright 2002-Sharon Souza, Ed.D, R.N., C.S.
A Nursing Tool for Insight
and Adherence in Psychosis
The State of Massachusetts Department
of Mental Health Treatment Guidelines
for Schizophrenia (1999) cites the LORS
as an example of an educational tool for
this population.
A Nursing Tool for Insight
and Adherence in Psychosis


Designed to identify strengths and
weaknesses in insight in order to
provide the basis for an intervention
to enhance and promote change and
recovery
This intervention (LORS Enabled
Dialogue) appears to increase insight
into mental illness
LORS Pilot Study




45 patients with psychotic illnesses
The LORS was administered by
clinicians
The BASIS 32 (Behavior and
Symptom Identification Scale was
self-administered
Instruments were completed at
baselines, 6 months and 12 months
LORS Pilot Study
Results



2 factors with a factor loading of a
least .58
Tentatively named Institutional
Support and Self-advocacy
Factor significantly correlated
(.661) with each other but not with
any of the BASIS 32 scores
LORS Pilot Study
Limitations – no formal training procedure

Factor analysis lf LORS = multiple
measures from same person

BASIS 32 correlations used
individual items rather than factors

LORS clinician administered, BASIS
32 self-administered
LORS Pilot Study
Conclusions – 2 distinct factors with
the LORS

Future research directed to
identifying whether changes in LORS
can contribute to improvement in
adherence and recovery
LED Intervention



Meet with clinicians most involved
with the patient (group home
director, case manager, therapists,
psychiatrist, etc.)
Get information about functioning in
areas on the LORS
Conduct clinical interview with the
patient
LED Intervention



Ask patient about their overall goals
Where would they like to be, what
would they like to be doing, what do
they want to change?
Common goals: Move into independent
living, find a job, meet a
girlfriend/boyfriend, get the staff to
stop hassling me
LED Intervention for Clinicians

A clinician encircles the LORS
categories for each column & row

Patients can have a “map” that has
items from each column

A preliminary scoring system ranks
each item through “anchor” points
LED Intervention for Patients



Go over brief directions with
patient
Ask that they encircle each item
that currently indicates where they
are on the LORS
Patients most often greatly
underestimate the extent of their
disabilities
Clinician
Levels of Recovery from Psychotic Disorders
NAME:
DATE:

ACTIVE ILLNESS
(DANGER TO SELF & OTHERS)
ACTIVE ILLNESS
(CONTROLLED PSYCHOSIS)
HOSPITAL WARD
STABLE BUT NOT IMPROVING
CUSTODIAL CARE
COMMUNITY RESIDENCE
STAFFED
SUPERVISION
locked ward
 24 hour nursing care

POTENTIAL FOR VIOLENCE
POTENTIAL FOR VIOLENCE

POSITIVE
SYMPTOMS OF
ILLNESS

very high risk
VOICES
 present most of the time,
occasional command
hallucinations
THINKING
VOICES
 present much of the time,
significantly affect
functioning
VOICES
 present much of the time,
sometimes able to ignore
THINKING
THINKING
POTENTIAL FOR VIOLENCE

VOICES
 less intrusive, viewed as
part of illness
THINKING
very insignificant
VOICES
 none or minimal
THINKING
clear, organized
KNOWLEDGE REGARDING
ILLNESS & ADHERENCE
TO TREATMENT
 poor & questionable
adherence
KNOWLEDGE REGARDING
ILLNESS & ADHERENCE
TO TREATMENT
 fair - some denial
KNOWLEDGE REGARDING
ILLNESS & ADHERENCE
TO TREATMENT
 fair - minimal denial
KNOWLEDGE REGARDING
ILLNESS & ADHERENCE
TO TREATMENT
 good
FACIAL EXPRESSION
somewhat distressed,
anxious or flat
FACIAL EXPRESSION
demonstrates spontaneous
humor
FACIAL EXPRESSION
 adequate range of
expression
FACIAL EXPRESSION
very distressed, anxious
or flat
REALITY TESTING
fair

more organized, unpleasant
minor risk
KNOWLEDGE REGARDING
ILLNESS & ADHERENCE
TO TREATMENT
 poor & complete denial

less bizarre, unpleasant
POTENTIAL FOR VIOLENCE

REALITY TESTING
more reality based


REALITY TESTING
good



FACIAL EXPRESSION
 less distressed, anxious

SPEECH
monotonous voice

SPEECH
initiates some conversation

SPEECH
better tone, volume

SPEECH
give-and-take dialogue

INTEREST IN OTHERS
does not initiate relationships

INTEREST IN OTHERS
shows interets in others

INTEREST IN OTHERS
cooperates with others

INTEREST IN OTHERS
avoids close relationships
VOLUNTEER OR WORK
very limited
concentration for tasks poor
 housekeeping room minimal

VOLUNTEER OR WORK
more time with tasks
improved concentration
 housekeeping own area
VOLUNTEER OR WORK
day treatment program
psychosocial rehab program
 sheltered employment
VOLUNTEER OR WORK
TEP (1/2 time/clubhouse)
supported education
 job training








PERSONAL HYGIENE CARE

poor
SOCIAL INTERACTION SKILLS
 very poor
ADVOCACY
moderate risk


SOCIAL SKILLS
POTENTIAL FOR VIOLENCE



WORK &
EDUCATION
high risk
INDEPENDENT LIVING
independent home
 flexible support from staff


REALITY TESTING
poor
NEGATIVE
SYMPTOMS OF
ILLNESS

rehabilitation house
 3/4, 1/2, 1/4 house

NORMALIZED ACTIVITY
goal directed, pleasant,
occasional problems
REALITY TESTING
 reality based most of time

bizarre, unpleasant
unlocked ward
 day hospital
 partial hospital
STABLE & IMPROVING
STAFFED SUPPORTED
APARTMENT
 includes other's home
INITIATES SELF ADVOCACY
no self advocacy for needs
no future orientation to
goals
PERSONAL HYGIENE CARE

grooming, hygiene requires
staff encouragement
SOCIAL INTERACTION SKILLS
 eye contact, body language
poor
INITIATES SELF ADVOCACY
limited self advocacy
limited future orientation to
goals




PERSONAL HYGIENE CARE

limited interest in grooming
SOCIAL INTERACTION SKILLS
 improved eye contact,
smiling, better non-verbal
communication
INITIATES SELF ADVOCACY
increasingly voicing own
desires
 more future goal orientation

PERSONAL HYGIENE CARE

adequate attention to
grooming
SOCIAL INTERACTION SKILLS
 good
INITIATES SELF ADVOCACY
improved sense of self
goals present & future
focused


SPEECH
good conversations
INTEREST IN OTHERS
enjoys relationships with
others
VOLUNTEER OR WORK
independent employment
P/T or F/T
 independent education
 independent voluntier

PERSONAL HYGIENE CARE

enjoys good personal
presentation
SOCIAL INTERACTION SKILLS
 involved in normal social
interaction
INITIATES SELF ADVOCACY
plans and executes long
term goals

Copyright 2002-Sharon Souza, Ed.D, R.N., C.S.
Patient
Levels of Recovery from Psychotic Disorders
NAME:
DATE:
ACTIVE ILLNESS
ACTIVE ILLNESS
(CONTROLLED PSYCHOSIS)
 (DANGER TO SELF & OTHERS)
HOSPITAL WARD
STABLE BUT NOT IMPROVING
CUSTODIAL CARE
COMMUNITY RESIDENCE
STAFFED
SUPERVISION
locked ward
 24 hour nursing care




POSITIVE
SYMPTOMS OF
ILLNESS
POTENTIAL FOR VIOLENCE

very high risk
VOICES
 present most of the time,
occasional command
hallucinations
THINKING
WORK &
EDUCATION
SOCIAL SKILLS
high risk
POTENTIAL FOR VIOLENCE

moderate risk
VOICES
 present much of the time,
significantly affect
functioning
VOICES
 present much of the time,
sometimes able to ignore
THINKING
THINKING
minor risk
POTENTIAL FOR VIOLENCE

VOICES
 less intrusive, viewed as
part of illness
THINKING
very insignificant
VOICES
 none or minimal
THINKING
clear, organized
REALITY TESTING
more reality based
KNOWLEDGE REGARDING
ILLNESS & ADHERENCE
TO TREATMENT
 poor & complete denial
KNOWLEDGE REGARDING
ILLNESS & ADHERENCE
TO TREATMENT
 poor & questionable
adherence
KNOWLEDGE REGARDING
ILLNESS & ADHERENCE
TO TREATMENT
 fair - some denial
KNOWLEDGE REGARDING
ILLNESS & ADHERENCE
TO TREATMENT
 fair - minimal denial
KNOWLEDGE REGARDING
ILLNESS & ADHERENCE
TO TREATMENT
 good
FACIAL EXPRESSION
somewhat distressed,
anxious or flat
FACIAL EXPRESSION
demonstrates spontaneous
humor
FACIAL EXPRESSION
 adequate range of
expression
FACIAL EXPRESSION
very distressed, anxious
or flat
REALITY TESTING
fair

more organized, unpleasant
POTENTIAL FOR VIOLENCE

independent home
flexible support from staff


less bizarre, unpleasant




REALITY TESTING
good



FACIAL EXPRESSION
 less distressed, anxious


SPEECH
monotonous voice

SPEECH
initiates some conversation

SPEECH
better tone, volume

SPEECH
give-and-take dialogue

INTEREST IN OTHERS
 avoids close relationships
INTEREST IN OTHERS
 does not initiate relationships
INTEREST IN OTHERS
 shows interets in others
INTEREST IN OTHERS
 cooperates with others

VOLUNTEER OR WORK
very limited
concentration for tasks poor
 housekeeping room minimal
VOLUNTEER OR WORK
more time with tasks
improved concentration
 housekeeping own area
VOLUNTEER OR WORK
day treatment program
psychosocial rehab program
 sheltered employment
VOLUNTEER OR WORK
TEP (1/2 time/clubhouse)
supported education
 job training








PERSONAL HYGIENE CARE

poor
SOCIAL INTERACTION SKILLS
 very poor
ADVOCACY

rehabilitation house
3/4, 1/2, 1/4 house
INDEPENDENT LIVING


REALITY TESTING
poor
NEGATIVE
SYMPTOMS OF
ILLNESS
POTENTIAL FOR VIOLENCE

NORMALIZED ACTIVITY
goal directed, pleasant,
occasional problems
REALITY TESTING
 reality based most of time

bizarre, unpleasant
unlocked ward
day hospital
partial hospital

STABLE & IMPROVING
STAFFED SUPPORTED
APARTMENT
 includes other's home
INITIATES SELF ADVOCACY
no self advocacy for needs
no future orientation to
goals
PERSONAL HYGIENE CARE

grooming, hygiene requires
staff encouragement
SOCIAL INTERACTION SKILLS
 eye contact, body language
poor
INITIATES SELF ADVOCACY
limited self advocacy
limited future orientation to
goals




PERSONAL HYGIENE CARE

limited interest in grooming
SOCIAL INTERACTION SKILLS
 improved eye contact,
smiling, better non-verbal
communication
INITIATES SELF ADVOCACY
increasingly voicing own
desires
 more future goal orientation

PERSONAL HYGIENE CARE

adequate attention to
grooming
SOCIAL INTERACTION SKILLS
 good
INITIATES SELF ADVOCACY
improved sense of self
goals present & future
focused


SPEECH
good conversations
INTEREST IN OTHERS
enjoys relationships with
others
VOLUNTEER OR WORK
independent employment
P/T or F/T
 independent education
 independent voluntier

PERSONAL HYGIENE CARE

enjoys good personal
presentation
SOCIAL INTERACTION SKILLS
 involved in normal social
interaction
INITIATES SELF ADVOCACY
plans and executes long
term goals

Copyright 2002-Sharon Souza, Ed.D, R.N., C.S.
LED Dialogue
Compare the 2 LORS – use
Motivational Interviewing style
 Draw attention to the differences
 Remind patient of their goals
 Indicate what treatments are
necessary in order for patient to
attain goals
 Frame the recovery possibilities with
treatment

Conclusion
Proposed Future LORS
Research

Further factor analytic work with a
large sample to test for reliability
and validity of the LORS

Manualization of the LORS and LED

Clinical trials of the LED