- Open Access
Applying intervention mapping approach to a program for early intervention in first-episode mental crisis of a psychotic type
Psicologia: Reflexão e Crítica volume 33, Article number: 3 (2020)
The holotropic mind perspective, an integral part of the framework of transpersonal psychology, has been considered a revolutionary approach to a certain spectrum of experiences in Non-ordinary states of consciousness (NOSC) which conventional approaches tend to treat indiscriminately as pathological processes, because PHM recognizes in these experiences their healing and evolutionary potential. This article describes the needs assessment, implementation, and evaluation of an experiential and educational program on the holotropic mind perspective and its praxis, Holotropic Breathwork® (HB), with students and professionals from the Group for Early Intervention in First-Episode Mental Crisis of a Psychotic Type of the University of Brasilia. The intervention aimed to establish change goals and objectives that would promote the adoption of the holotropic mind perspective’s elements, such as a framework to broaden and strengthen mental health programs that assist people experiencing NOSC. The stages developed, inspired by the Intervention Mapping protocol, included a needs assessment; elaboration of change objective matrices; selection and description of methods based on theory and their applications; conception, planning, and implementation of the intervention; and results evaluation. Participants reported that the intervention allowed the expansion of their theoretical-conceptual and technical frameworks, giving them a less pathologizing understanding of and approach to NOSC and allowing them to perceive and manage such states, not as indiscriminately pathological expressions, but as phenomena inherent to the human condition that can be accepted and cared for without the exclusionary and exhaustive bias of mental disorders. Limitations and practical implications are discussed.
Human history presents, in every society and culture, a wide array of therapeutic approaches toward health and illness, including the psychological. The first investigations of psychology and psychiatry strongly emphasized the field of neuroscience, presuming that one could find in the body the causes of various psychological phenomena as well as the solutions to these problems—something that has only been reinforced by the advent of psychopharmacology (Costa, 2017; Shorter, 2008). While recognizing the importance of these early approaches, a large part of the theoretical and technical framework applied to the study and management of psychological phenomena is underpinned by the logic of the discourse between the normal and the pathological in mental health (Lopes, 2009). One may infer that the practice of pathologization of various psychological phenomena, observed and attested in the scientific literature (Wetzel, Pavani, Olschowsky, & Camatta, 2017), has its deepest roots in the absence, still, of epistemological and clinical instruments in the fields of traditional psychology and psychiatry that could offer non-pathologizing explanations or management. Their current theoretical-technical framework has exposed several psychological phenomena related specifically to experiences of non-ordinary states of consciousness (NOSC), explained today exclusively through the lens of illness.
In this scenario, the holotropic mind perspective (HMP), proposed by Czech psychiatrist Stanislav Grof, becomes important, as it advocates stepping back from this pathologization bias and taking a certain spectrum of NOSC experiences as qualitative changes that may hold developmental potential when well-managed and should not, a priori, be considered anomalous mental digressions (Grof, 1987, 2015). The researcher distinguishes, nonetheless, between the NOSC experiences that cause suffering and have no evolutionary potential and those which, with or without suffering, have the potential to be heuristic, transformational, and healing (Grof, 2015). Throughout 60 years of work and studies, the author, accompanied by a worldwide community of therapists and researchers, has been endorsing the dissemination of his theoretical framework and the outcomes of applying the technique developed by him, i.e., holotropic breathwork as a less pathologizing approach for the understanding, management, and therapeutic integration of NOSC experiences (Afanasenko, Emelianenko, & Emilianenko, 2014; Brewerton, Eyerman, Cappetta, & Mithoefer, 2012). As the value of a non-pathologizing approach to NOSC-connected psychological phenomena has been evidenced, the experience of the Group for Early Intervention in First-Episode Mental Crisis of a Psychotic Type (GIPSI) from the Center for Psychology Assistance and Study (CAEP) at the University of Brasilia (UnB) is highlighted. Established in 2001, this group is inspired by the British model of early intervention in psychosis to welcome and care for people experiencing NOSC, even when only prodromes are present, to minimize or interrupt the psychological aggravation that commonly occurs and which grows the longer first intervention is delayed (Allard, Lancaster, Clayton, Amos, & Birchwood, 2018; Marshall & Rathbone, 2011; Reichert & Jacobs, 2018; Schmidt et al., 2015).
Taking HMP as a starting point, the stages of an educational and experiential program around HMP and its praxis, HB, were recorded. HB’s development was inspired by the intervention mapping protocol and stresses the stages of needs assessment; the intervention’s expected results; selection and description of methods based on theory and their applications supported by evidence for their success; conception and implementation of the intervention carried out; and results evaluation (Bartholomew, Parcel, Kok, Gottlieb, & Fernández, 2011; Murta & Santos, 2015; Schaafsma, Stoffelen, Kok, & Curfs, 2013). Intervention mapping (IM) is a systematic approach to plan interventions used worldwide (De Lepeleere, Verloigne, Brown, Cardon, & De Bourdeaudhuij, 2018; Lamort-Bouché et al., 2018), which holds that health interventions based on theory and their applications tend to be more successful (Bartholomew et al., 2011). The intervention aimed to establish change goals and objectives that would promote the adoption of HMP elements, such as a framework to broaden and strengthen mental health programs that assist people having NOSC experiences.
This study has the purpose to describe the application of IM to the planning, implementation, and evaluation of an experiential and educational program on the holotropic mind perspective and its praxis, Holotropic Breathwork® (HB), with students and professionals from the Group for Early Intervention in First-Episode Mental Crisis of a Psychotic Type of the University of Brasilia.
The stages of the educational and experiential program in HMP that were performed inspired by IM, from needs assessment to results achieved, are presented as follows (Fig. 1). The study was approved by the Committee for Ethics in Human and Social Sciences of the University of Brasília.
In the needs assessment stage, the problem the intervention focuses on should be scrutinized, seeking an approximation with reality into which is inserted, along with the actors involved in it, the interactional dynamics that occur in the scenario, and related behaviors. This investigation can be carried out with qualitative methods, such as interviews or focus groups (Köche, 2016). This investigation’s results can be used in later stages to foster a better understanding of the intervention’s objective, the behavioral and environmental determinants involved in it, and greater clarity regarding the objectives of change and performance as well as to indicate the best intervention strategies and their possible outcomes (Bartholomew et al., 2011).
The sample who participated from needs assessment was composed by 30 people linked to GIPSI Program, among interns, volunteer professionals, and researchers. GIPSI is a Standing Extension Program of the Department of Clinical Psychology of the Institute of Psychology at the University of Brasilia. It consists of an interdisciplinary team of professionals, volunteers, interns, and researchers from the fields of psychology, psychiatry, nursing, social service, occupational therapy, and others. This program focuses on the welcoming and care of people in their first mental health crisis and their relatives as well as on the development of research related to severe psychological distress and its management (Freitas & Costa, 2018).
The needs assessment was performed via a set of methods (Kok, Peters, & Ruiter, 2017), including documental analysis, literature review, participant observations, and semi-structured interviews. Initially, a documental analysis consisting of the reading of the GIPSI Orientation Manual (GIPSI, 2018) and the results of internet searches for pages with information about the program, which returned the GIPSI Facebook Page (GIPSI, 2019) and UnB’s main website (http://www.unb.br).
The literature review, focused on the description of the GIPSI experience, consisted of searching using the string “Grupo de Intervenção Precoce nas Primeiras Crises do Tipo Psicótica.” The results from literature databases Brazilian Virtual Health Library-Psychology (BVS-Psicologia) and Brazilian Coordination Portal for the Improvement of Higher Education Personnel (Portal CAPES) was one article and, at Google Scholar, one article and one citation, whose original article was recovered at the Pluralities in Mental Health Journal website. For the observation and interview, a script was prepared, adapted from IM (Bartholomew et al., 2011; Rohrbach, 2014), which guided the observation of aspects of GIPSI Program management and the interview with a key informant (KI) in this program (Table 1). Participant observation took place at the welcoming meeting for new GIPSI team members. The program coordinators held a dialogued exhibition presenting the program history, mission, and overview as well as an evaluation of the previous year and perspectives for the current year, 2018. There was a presentation and then testimonials of group members, including professionals, volunteers, interns, and researchers. Observations were recorded in a logbook (Severino, 2017). The interview was conducted later by one of the professionals who works as a volunteer in the program, a KI by virtue of clinical experience, and time engaged at GIPSI. The strategy used for data collection was to send the script via the WhatsApp messaging application and receive the responses in audio files.
Intervention expected results: changes objectives matrix
In this stage, based on the information acquired in the previous stage, the goal was to elaborate a matrix of interactions between performances objectives, change objectives, and behavioral determinants (Bartholomew et al., 2011; Murta & Santos, 2015; Schaafsma et al., 2013). The GIPSI members were considered the intervention’s priority target population and, as implementers, the first author and two HB facilitators, qualified and certified by the Grof Transpersonal Training® (GTT), were requested for this activity. The choice of these individuals was due to the nature of the work, developed by the GIPSI Program, in which they welcomed and followed-up with people in psychological distress, a phenomenon which, in the scope of this program, is taken as an integral aspect of existence. To be avoided at all costs is its a priori framing as a nosographic classification of mental disease. Instead, it seeks to understand it from a broader phenomenological perspective that suggests a more integrative management of these experiences (Costa, 2010). That, ultimately, is the clinical standing sought to be reinforced in the target group, based on HMP, especially as regards NOSC experiences. Here, the expected outcomes or desired changes were also listed for each change objective indicating determinants and related performance goals. This allowed, at a later stage, defining the best intervention strategies and their possible outcomes (Bartholomew et al., 2011; Kok, 2014). The goal of this intervention was reiterated as well through the inclusion by members of the GIPSI Program of HMP elements (Grof, 2015) in their clinical practice as a less pathologizing psychological approach to people who had experienced NOSC.
The psychological theories that analyze behavioral changes make the inseparability between those changes and behavioral determinants explicit, and this identification is indispensable to the effort undertaken to change a behavior or to adopt new behaviors. Determinants can be defined as “psychological variables or regulatory processes that are assumed, on the basis of empirical or theoretical evidence, to be causal antecedents of behavior” (Kok et al., 2016, p. 3). They can be of an emotional or cognitive nature and/or related to beliefs or, moreover, have their origin in automatic associations, be it at an individual level or with environmental resonance. The change objectives comprise precise changes in behaviors that are proposed based on their determinants. In this sense, this study identified cognitive determinants, of both an awareness order and a knowledge order, as well as attitudinal determinants of skills and self-efficacy. Each performance objective listed below is related to one of these determinants, through specific change objectives within which the professionals: (1) Assess their level of knowledge regarding different psychological approaches, including HMP; (2) demonstrate being open to a theoretical and experiential approach to HMP and its praxis, Holotropic Breathwork®; (3) indicate reasons for a theoretical and experiential approximation to HMP and its praxis; (4) decide to join the educational and experiential program on HMP and HB and evaluate their resonances with their health and quality of life; (5) participate in the project’s educational program, attending the workshops offered; (6) participate in the project’s experiential program, attending the HB workshops; and (7) include HMP aspects in their theoretical framework and in their clinical approach to people in mental health crisis. A description of the interactions between performance objectives, change objectives, and behavioral determinants is shown in Table 2. The parameters defined were the identification of participants according to Stanislav Grof’s explanatory model for NOSC phenomena and the adoption of elements from this perspective in the clinical approach of therapists. Such parameters were also the essential goal of this initiative.
Selection and description of methods based on theory and their applications
In this stage, methods based on theory and evidence that can be used to change the behavior determinants, which have been evidenced and translated into performance objectives in previous stages, are selected. Here, all the conditions for the application of the selected methods must be ensured to promote efficacy. Next, the methods need to be translated into practical applications, which means effecting activities and materials, and adapting them to the specific target group and intervention context, in this case, GIPSI members. At this stage of the planning, the participation of target-group members and implementers is especially important (Peters, 2014). The methods proposed are the result of a literature review of their pertinence and evidence for efficiency when applied. In addition to scientific evidence, the researchers’ broad professional and academic experience in using the methods also contributed to their choice.
The related methods are mentioned as follows:
Active learning—a method that fosters learning through goal-oriented practice (Kelder, Hoelscher, & Perry, 2015; Kok et al., 2016) that has been applied through a mix of activities such as expository dialogue, which consists of an explanation focused on HMP during which theoretical support was offered for the articulation of knowledge, cognitive enrichment, debating of view, and experiences concerning the subject (Svinicki & Mckeachie, 2012); brainstorming—group activity that fosters the exploration and sharing of sensitive and rational material addressing the triggering theme (Svinicki & Mckeachie, 2012).
Cooperative learning—encompasses positive interdependence, face to face verbal interaction, individual responsibility, social skills, and task processing in group environments (Gillies, 2016; Johnson, Johnson, & Smith, 2014; Kok et al., 2016).
Self-evaluation—increases awareness of oneself and of one’s personal and affective cognitive performance in a practical and learning environment. It is based on the transtheoretical model of behavior change and encompasses the following stages: pre-contemplation, contemplation, preparation, action, and maintenance (Kok et al., 2016; Prochaska, Redding, & Evers, 2015).
Defining goals and gradual tasks—includes planning future activities related to the intended objectives and accepting tasks whose level of difficulty gradually increases. Both methods are based on the theory of self-regulation (Kelder et al., 2015; Kok et al., 2016).
Feedback—this method allows, based on learning objectives and reference criteria as well as self-analysis, evaluation and feedback between peers and the activity coordinator (Suskie, 2018). With this method, the offer of information was favored to participants in relation to their cognitive or practical performance, considering the activities proposed (Kelder et al., 2015; Kok et al., 2016).
Participation—this method assures high participant engagement in the discussion and decision-making for change actions (Cummings & Worley, 2015). It can be applied through roundtable discussions as a participative and problematizing strategy that fosters and promotes debate and collective knowledge construction (Machado & Moura, 2016).
Problematizing—this method abets the exercise of action-reflection-action, having extracted from reality and previous knowledge all means to acquire new knowledge and new skills. It has been widely applied in contexts of andragogy and popular education (Ausubel, 2008; Freire, 2011; Freire, 2014).
Literature review—a method of scientific research based on empirical studies, other literature review articles, theoretical articles, or experience reports, via database or abstract searches of periodicals that allows a theoretical deep-dive into a specific topic (Köche, 2016). It contributes to evidence-based practice (LoBiondo-Wood & Haber, 2017).
Holotropic Breathwork®—a method based on HMP (Grof, 2015). It is a mind-body practice developed in a therapeutic environment that involves a hyperventilation technique and is accompanied by evocative music to propitiate the attainment of heightened states of consciousness. Because of these states’ healing, transformative, and heuristic potential, they are called NOSC. The practice should be conducted by qualified professionals certified by Grof Transpersonal Training® (Afanasenko et al., 2014; Grof, 1987; Grof, 2015). A summary of the methods and their applications related to the determinants and change objectives to which they apply is set out in the Matrix of Change Objectives (Table 3).
Conception, planning, and implementation of the intervention
In this stage of the program development, the objective was to integrate practical applications within an organized plan in which all the elements already described in the previous steps are gathered (Bartholomew et al., 2011). Meetings were held with GIPSI members to introduce the proposal, making them aware of the theoretical and practical dimensions of the holotropic mind approach as well as of the educational and experiential program proposed. Later, this was also done with the Institute of Mental Health team. In this stage, strategies for the adoption, implementation, and sustainability of the program in the context of its application and target group were assessed (Kok et al., 2017). All resources necessary for the application of the methods, including facilities, furniture, audiovisual and sound resources, mats and cushions for the breathwork practice, stationery for the making of mandalas in the integration stage of the experiment, and other general-objective materials were secured and provided. Implementers and participants were mobilized with the aid of members of the intervention’s target group (Bartholomew et al., 2011; Kok, 2014; Stralen et al., 2008). A partnership between researchers linked to University of Brasilia and the Institute of Mental Health, a unit of the State Health Secretary of the Federal District, Brazil, was established. The terms of this partnership were the assignment of facilities to carry out the educational and experiential workshops provided for in the program in exchange for the inclusion of professionals from service careers in the activities to be developed in the program. All actors in this stage offered contributions to the improvement of the offerings and, later on, provided feedback about the development of the activities and their personal and environmental impacts. In the service, people who formed a support network for the work were identified, ensuring fluidity in the development of interventions.
The results evaluation stage included the development of an evaluation plan based on previous stages. The evaluation was directed at the process and results indicators (Bartholomew et al., 2011). As process indicators, early action adoption in the intervention plan was verified, highlighting the two meetings of the educational and experiential program during which expository dialogues focusing on the presentation of the holotropic mind perspective and HB practices were conducted. Result indicators were obtained through content analysis (Bardin, 2016) of what the participants’ said during the roundtable discussions, at the end of workshops, and their answers to the electronic interview sent by e-mail and WhatsApp to participants.
This interview included questions related to conceptions of psychological distress, NOSC experiences, theoretical anchorage of the participants’ clinical practice, and perceptions of the HMP presented during the workshops and its praxis, HB, which they could experience during the program implementation. The questions also encompassed the resonances in personal development and clinical practice of the new theoretical concepts around HMP and perceptions of the participants’ NOSC experiences experienced through the practice of HB. In this stage, returning to the established goal and to the performance and change objectives defined was indispensable for verifying their scope regarding their inclusion by the mental health program therapists of HMP elements in their clinical approach.
Results and discussion
The analysis of the results evaluation data showed that GIPSI is a program consisting of a multidisciplinary team whose mission is to act early in welcoming and assisting people, and their families, in their first-episode mental crisis and to develop activities in consonance with the principles of universality, integrality, and equity of Brazil’s publicly funded health care system (GIPSI, 2018) and of the Brazilian Mental Health Law (Act No. 10,216, 2001). It is an expanded clinic that offers a distinct intervention that aims to provide the best support possible during the crisis (Freitas & Costa, 2018). GIPSI emerged around the problem of how to assist people undergoing severe psychological distress in situations of mental health crisis, understood here as psychosocial dislocation: a disruption or change in personal balance in effect up to this point requiring an intervention to assure the protection and well-being of the subjects until they return to states of equilibrium or less suffering (Costa, 2017; Schmidt et al., 2015).
Prior to its implementation, the program developers identified that, in the course of caring for people in mental health crisis, family and professionals often resort to hospital admittance, thus establishing a cycle of stigmatization, aggravation, and chronification of mental conditions that, if managed another way, would lead to less iatrogenic outcomes (Grof, 2015). In that sense, and based on the English model of early intervention in psychosis (Marshall & Rathbone, 2011; Reichert & Jacobs, 2018; Schmidt et al., 2015), a set of studies and early assistance for people with signs of psychological distress was implemented in 2001, taking as assumptions the observation that hospital admittance had not been shown to be the best option for those who present psychotic suffering prodromes and that proper and early management can interrupt the ongoing aggravating situation (Costa, 2017; Freitas & Costa, 2018). Clinical experience, including that of the University of Brasília’s Center for Psychological Assistance and Study, has revealed an open field of interventions for which no alternative was yet in place, as acute cases were often referred to mental health emergency services.
With that in mind, since its implementation, the program has been directed at people under severe psychological distress in their first-episode mental crisis of a psychotic type. Family participation has also been a criterion for inclusion in the program. The systemic theory (Costa, 2010) recommends broadening the scope of care from the individual to the family, as exemplified by the interviewee's perception that: “The suffering includes everyone involved, father, mother, child.” (KI). Criteria that excluded individuals from participating in the program were cases in which there are organic causes for the psychological situation (associated clinical aggravation) and cases related to psychoactive substance abuse. However, all cases are evaluated individually to determine whether they will be a part of the program or not.
Regarding the expected results of the program, as hospital admittance determinants were identified as an undesirable intervention (Barreto, 2014), efforts were made to avoid hospitalization as well as indiscriminate use of medication by offering individual and group therapy assistance in a personalized and humanized way. Weaknesses in the management of these clients were also identified, such as not including families in the therapeutic care. The program has been assisting the families in a concomitant and integrated way to care for patients. In this sense, management based on relevant and changing determinants and without hospitalization and in a humanized and integrated way with crisis reversal and family support is a priority outcome of the program. As for the investigation of methods based on theory and evidence and their application concerning the program, a variety of therapeutic strategies starting with a 24-h crisis hotline are used. The utilization of face-to-face reception, as opposed to screening, is based on the National Humanization Policy of the Brazilian Ministry of Health (Ministério da Saúde, 2006), which promotes the use of listening and understanding in order to learn the meanings assigned by the subject to his own experience while simultaneously allowing the participants a dialogical construction of new meanings (Lévy, 2001).
This strategy avoids a priori psychologizing or psychopathologizing the subject’s demands and experiences and invests instead in the phenomenological exercise of understanding and acting in the realm of experiences and relationships (Freitas & Costa, 2018). According to the perception of the KI, the diagnostic classification systems: “[...] do not allow comprehension of the phenomenon’s whole complexity” (KI). The use of systems such as the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) or the International Statistical Classification of Diseases and Related Health Problems (ICD-10) circumscribes not only one’s reading of psychological phenomena but also of therapeutic intervention.
Moreover, in the course of psychotherapeutic care, approaches from different schools are used, such as psychoanalysis, gestalt, cognitive behavioral, and psychodrama, according to the therapist’s familiarity with these therapeutic techniques. Furthermore, philosophical approaches to care and professional ethics and complexity theory are also considered. In the program evaluation, it was clear that there was no involvement of members of the community or the target group (patients and relatives) in the initial planning actions of GIPSI. However, these groups have a privileged space to talk during the therapeutic process and group activities, in which they “can offer their impressions,” having been invited to evaluate the care and the propositions for improvement of the initiatives connected to the program.
Regarding the program development, it was observed that the model of early intervention in psychotic crises developed by GIPSI, albeit inspired by the English experience of early intervention in psychotic crisis (Marshall & Rathbone, 2011; Reichert & Jacobs, 2018; Schmidt et al., 2015), distances itself from this model while advancing some of its aspects, notably abandoning the “psychosis” diagnosis and evaluation based on prodromes of this pathology to look at the signs of disorganization and suffering that could indicate a mental health crisis (Freitas & Costa, 2018). Another peculiarity of the GIPSI Program is the inclusion of the family in the therapeutic care based on the understanding that suffering reverberates from the individual into their family environment. Experiments prior to the constitution of the program were carried out when the group was created. They were coordinated by the program’s creator and academics and graduate students participated as well. The aim was to conduct studies of severe psychological distress and crisis response. The consolidation of the program arose from this experience (Freitas & Costa, 2018; Oliveira, 2011).
As for the program’s feasibility, GIPSI’s offerings consist of a crisis hotline, an interprofessional welcoming of people in their first severe mental crisis, psychotherapy and individual and family guidance, psychiatric consultation, social and occupational assistance in the care unit or outside it, and psychosocial and diagnostic evaluation. During the program’s presentation, it was emphasized that the secrecy and confidentiality of customer identities and information are safeguarded in accordance with ethical standards (GIPSI, 2018).
Among the barriers to the program’s development, the precariousness of the psychosocial care network of the Federal District, which lacks sufficient psychosocial assistance centers thus resulting in GIPSI being overloaded, was cited. As barriers, paradigm divergences in the assistance model were noted, as the caregivers entering the program often bring from their background a hospital and medical perspective concerning the management of people in mental health crisis. It was mentioned that approximately 20% of the people and families who begin their treatment in the program quit, making adherence a challenge. Regarding these challenges, the interviewee reveals:
There are many challenges, one of the main is related to public policies for mental health services. [The Federal District] is still one of the worst in the national ranking. Another problem is that there are professionals who still have a view more related to hospitalization in all cases. (KI)
Some other challenges are posed for the program, such as those related to interdisciplinary and interprofessional work, integration between theory and practice, and the need for openness to a paradigmatic deconstruction. To overcome the identified barriers, the program proposes methodological workshops to discuss aspects of the program’s structure, process, concepts and results, and experiential workshops in which relational aspects between group members and care with the caregiver are addressed. These workshops are held every 6 months and can be organized on special dates if there is a need for technical and methodological alignment. In addition to this strategy, the whole team undergoes individual and collective supervision by the program staff. This includes the evaluation of the work process, the survey of limitations and needs, the sharing of experiences overcoming barriers, and the formulation of propositions to overcome them.
Regarding the program’s evaluation methods, it was observed that GIPSI members use internal and external strategies. In addition to the previously mentioned workshops and team supervision, evaluation has been carried out through assessment by research funding organizations, such as the Brazilian Coordination for the Improvement of Higher Education Personnel (CAPES). Also, through publications—be they books, articles, theses, or dissertations—GIPSI members raise visibility of the program experience and boost its recognition by the scientific and care-giving communities. One final evaluative strategy is the organization of scientific and cultural events, where this small community presents its products and services, open to public judgment. Today, around 40 people work at GIPSI, including professionals, volunteers, interns, researchers, and graduate students (masters and doctorate candidates). The evaluation of the GIPSI program, considering the steps proposed for the planning and development of health interventions, allowed greater appropriation of the context in which the educational and experiential program in HMP and its praxis, HB, to be developed.
Based on the needs survey and according to the planning established, the envisaged educational and experiential program was conducted. Telephone and e-mail communication were carried out with facilitators certified by Grof Transpersonal Training® to formalize the invitation to conduct HB workshops. Plane tickets and lodging were provided as the implementers lived outside Brasilia. All equipment and materials needed to fulfill the educational and experiential program were provided. The partnership with the Institute of Mental Health for the assignment of the facilities was secured after a visit to the unit, and formalization of the reservation request was made via the Federal District Health Authority’s Electronic Information System. As a counterpart to the partnership with the institute, vacancies were reserved for service professionals and volunteers interested in the holotropic approach. Visits to GIPSI and the institute were made during team meetings to present the educational and experiential program, including awareness-raising and invitations to participate in the initiative.
The educational and experiential program took place in two workshops, the first on April 26–28 and the second on June 15–17, 2018. The structure of the workshops was identical. On the first day of each workshop, the activities were focused on expository dialogues (Svinicki & Mckeachie, 2012), conducted by the first author, in two sessions of approximately 2 h each during which they presented HMP concepts and fundamentals and HB practice as well as the architecture of mental disorders according to HMP. Following the expository part of both workshops, roundtable discussions were conducted, lasting a maximum of 2 h, during which participants made suggestions, asked questions, and received guidance on the experiential activities in HB to be developed in the following days. The HB sessions took place throughout the second and third days of each workshop, followed by an integration activity through plastic expression (mandala making) and discussion circles about the experiences, for a total of two 10-h sessions of activities in each workshop. In the program’s activity schedule, 12 h were allocated for educational activities and 40 h for experiential activities, adding up to 56 h of activities in the two workshops, as detailed in Table 4. The first workshop was attended by 19 people: ten professionals, five students, and four volunteers. In the second, there were 20 people: ten professionals, three students, and seven volunteers. Seven professionals, one student, and three volunteers participated in both workshops.
Intervention outcomes evaluation
To begin the evaluation of intervention outcomes, it should be noted that of the 28 people who participated in the workshops, 22 of them answered the interviews, of which 11 were professionals, seven were students, and four were volunteers. For the objectives of the following analyses, it was decided not to use with the volunteers’ responses as they were not clinical practitioners and thus lack this point of view. In fact, of the 18 professional (P) and student (S) respondents, only five (27.75%) reported they had had experienced NOSC before the HB practice offered in the program. As for the NOSC experiences that occurred during the HB workshops, all 18 (100%) respondents stated that it was a transformational experience that impacted their personal and professional development:
After the experience with holotropic breathwork, I carried out two group therapy sessions and managed to conduct the session more serenely than usual, finding ways to work with what is common to the group as a whole in an easier way." (P3)
"It was for me an experience that promotes self-knowledge and development." (P4)
"I had a huge increase in my personal analysis from my holotropic breathwork experiences. From these experiences, I managed to advance my therapeutic process a lot. It is much more intense and is giving very nice results. (P11)
We recognize that the realization of the present educational and experiential program, built upon and inspired by the Intervention Mapping Protocol, was successful in choosing and implementing the methods and their outcomes. Active learning methods (Kelder et al., 2015; Kok et al., 2016; Machado & Moura, 2016), cooperative learning (Svinicki & Mckeachie, 2012), and participation (Cummings & Worley, 2015), applied through strategies such as expository dialogue, roundtable discussions, and the experience of the HB practice, allowed participants’ learning to be guided according to the established goals and with fruitful sharing of knowledge and therapeutic practices. These were common among and unique to the participants and included concepts and fundamentals regarding HMP and its praxis, HB, in an innovative way within the group: “It was a moment of great self-enlightenment. First, we had a theoretical exposition, shared our expectations and introduced each other and the concepts.” (P3)
The program provided an environment for participants to express themselves regarding the evaluation of the activities developed as well as for self-evaluation (Kok et al., 2016; Prochaska et al., 2015) concerning personal enjoyment rather than the content offered in that context. The evaluation process led to reflections on the design and assumed goals and gradual tasks (Kelder et al., 2015; Kok et al., 2016) with significant raising the awareness of everyone about the adoption of HMP elements in future clinical practice:
I feel much closer to people [...] This whole process has been important to me and I see great progress in my relationship with everyone. In my therapeutic work, in my relationships with clients, and with colleagues in supervision, I improved considerably in quality and personal confidence. (P11)
The discussion roundtables provided feedback (Suskie, 2018) and self-regulation time (Kelder et al., 2015; Kok et al., 2016), enriching all the participants as well as the group of implementers regarding how the program was conducted.
The practice of HB (Grof, 2015) has showed itself to be a method as well as a channel for problematization (Ausubel, 2008; Freire, 2011; Freire, 2014), mainly through experimentation by the groups of participants:
In addition to the therapeutic potential experienced, specifically triggered by HB, I think it is even more important to share that the experience as a whole, taking into account the people present, the facilitators, and the place, allowed me to experience a place of relaxation, lack of control, madness, ugliness, weirdness, outburst, beauty, ecstasy, and catharsis without any judgments. There was a feeling that I was allowed to express the way my organism felt it needed to be expressed that enabled me to take advantage of the therapeutic potential of the technique [...] The value that the experience provided as a whole was that I could be who I needed to be at that moment, with my body, with my bioenergy, and the more sincere, the greater the healing potential (P8)
The practice of HB has successfully allowed the exercise of action-reflection-action within the explanatory model of mind proposed by psychiatrist and researcher Stanislav Grof, wherein the existence of an expanded mental cartography includes remembrance levels beyond that of biographical memory, commonly studied by the traditional psychological schools. These different levels in the perinatal and transpersonal remembrance dimensions can be accessed when experiencing, in a spontaneous or induced way, NOSC. Such experiences, when well-received in an appropriate therapeutic environment, as proposed by the practice of HB, can be promoters of healing and personal development (Afanasenko et al., 2014; Grof, 1987; Grof, 2015; Rhinewine & Williams, 2007).
At this point in the analysis, resuming the action planning, it can be stated that the development of this educational and experiential program achieved the proposed goals, resulting in 16 (88.8%) of the respondents recognizing that the holotropic mind perspective is a less pathologizing approach to NOSC phenomena than conventional psychological approaches, which is represented in the following statements:
A powerful healing and self-encounter tool, capable of fostering inner peace, boosting self-esteem, and rescuing the spiritual dimension. (P3)
Yes, mainly for not judging the psychological phenomena that need to be manifested. (P8)
Undoubtedly, first, it does not treat psychological demands as diseases, but as part of the human being. In addition, it refers a lot to the phenomenological approach that brings us precisely this idea of going against the pathologization of mental suffering. (S1)
Only two (11.2%) of the respondents did not comment on this topic. Seventeen (94.35%) respondents agree with the statement that the practice of HB is a valid, important, and recommendable mental health tool for people who experience NOSCs. Here are some statements regarding HB practice:
Very interesting technique of self-knowledge, making it possible to experience deep levels of consciousness, as I observed. (P4)
The other conventional practices in mental health do not have such an ability to access our subconscious mind so assertively, to the point that we ourselves are the authors of our emotional and physical healings. (S1)
One (5.55%) of the respondents did not categorically state a standing:
I could not come to a 100% conclusion. (P1)
Of the 18 professionals and students respondents, 17 (94.35%) expressed interest in deepening their knowledge and willingness to include elements of HMP in their theoretical framework and clinical practice with people reporting NOSC experiences. The following statements are representative:
I will use many of its elements. It certainly prepared me better to welcome the user. (P5)
In fact, the perinatal stages (levels reminiscent of the Grofian perspective) are something to pay attention to; I have even reflected a lot on how this (re)birth process reverberates in my own life. (P8)
I would consider other dimensions, such as the perinatal and the perspective regarding the subject's relationship with reality. (P10)
In particular those [elements] that understand spiritual emergencies and the transpersonal scope of consciousness may be very relevant in dealing with the 'unspeakable' suffering of the people I treat in the future (S7)
Concluding the evaluation of the educational and experiential program implemented by us and underpinned by the IM protocol, it is notable that the participants’ acquisition of HMP allowed the expansion of their theoretical-conceptual and technical frameworks, making them aware of a less pathologizing understanding of and approach to NOSC phenomena. This in turn allowed the perception and management of such phenomena, not indiscriminately as pathological expressions, but as phenomena inherent to the human condition that can be accepted and cared for without the exclusionary and exhaustive bias of mental disorders.
One of the limitations of the educational and experiential program described here is the fact that the needs assessment for the GIPSI Program was conducted based on the few documents available in academic databases, one participant observation session, and one interview, though it was with a key informant. The low adherence of GIPSI Program members to the initiative, the target group of our study, also set a limitation. Although it was overcome by the inclusion of members of the ISM mental health program, and, in the end, the results of the initiative were broader and more positive than those initially envisioned, as two mental health programs were included in the process, rather than the single one originally planned.
The experience of using the IM approach was of crucial importance for the success achieved by the initiative as it enabled the program to foster knowledge capable of guiding a clinical and social practice that offers greater support and care to the subjects and collectives in mental health care programs, such as those of GIPSI and ISM. The present exercise of using the Intervention Mapping protocol instrumentalized, in a less intuitive way, our intervention propositions, grounding them in theoretical and methodological bases and in evidence for their successful practical applications. Likewise, the unconstrained validation of participants of the value of the holotropic mind perspective shows that these contributions can be added to those already achieved by clinical psychology, expanding theoretical support for the deconstruction of discourse between normalcy and pathology, favoring a more respectful and dignified treatment of people who experience unique psychological phenomena such as NOSC.
Availability of data and materials
Data are available from the first author (email: email@example.com).
Center for Psychology Assistance and Study
Brazilian Coordination for the Improvement of Higher Education Personnel
Group for Early Intervention in First-Episode Mental Crisis of a Psychotic Type
Grof Transpersonal Training®
Holotropic mind perspective
Intervention mapping protocol
Non-ordinary states of consciousness
University of Brasilia
Afanasenko, I. V., Emelianenko, V. A., & Emilianenko, A. V. (2014). Spiritual transformation: a qualitative-quantitative analysis of the application of the holotropic breathwork method. Journal of Transpersonal Research, 6(1), 25–37.
Allard, J., Lancaster, S., Clayton, S., Amos, T., & Birchwood, M. (2018). Carers’ and service users' experiences of early intervention in psychosis services: implications for care partnerships. Early Intervention in Psychiatry, 12(3), 410–416 https://doi.org/10.1111/eip.12309.
Ausubel, D. P. (2008). Aquisição e retenção de conhecimentos: uma perspectiva cognitiva [Knowledge Acquisition and Retention: a cognitive perspective]. Lisboa: Plátano.
Bardin, L (2016). Análise de conteúdo [Content Analysis] (L. Reto, Trad.). São Paulo Edições 70.
Barreto, A. A. (2014). Intervenção nas situações de crise psíquica: dificuldades e sugestões de uma equipe de atenção pré-hospitalar [Intervention in Situations of Mental Crisis]. Revista Brasileira de Enfermagem, 67(5), 708–714 https://doi.org/10.1590/0034-7167.2014670506.
Bartholomew, L. K., Parcel, G. S., Kok, G., Gottlieb, N. H., & Fernández, M. E. (2011). Planning health promotion programs: an intervention mapping approach. Third edition. San Francisco, CA: Jossy-Bass.
Brewerton, T. D., Eyerman, J. E., Cappetta, P., & Mithoefer, M. C. (2012). Long-term abstinence following holotropic breathwork as adjunctive treatment of substance use disorders and related psychiatric comorbidity. International Journal of Mental Health and Addiction, 10(3), 453–459 https://doi.org/10.1007/s11469-011-9352-3.
Costa, I. I. (2017). A crise psíquica enquanto paradigma do sofrimento humano. (Re)Pensando o psíquico como expressão do existir e seu cuidado [Mental Crisis as a Paradigm of Human Suffering: (Re)Thinking the psychic as an expression of existence and its care]. In: Nilton Júlio de Faria e Adriano Furtado Holanda. (Org.). Saúde Mental, Sofrimento e Cuidado - Fenomenologia do Adoecer e do Cuidar. Coleção Saúde e Psiquê. Curitiba: Editora Juruá, p. 222.
Costa, Liana Fortunato. (2010). A perspectiva sistêmica para a Clínica da Família [The systemic perspective for clinical family psychology]. Psicologia: Teoria e Pesquisa, 26(spe), 95-104. https://doi.org/10.1590/S0102-37722010000500008
Cummings, T. G., & Worley, C. G. (2015). Organization development and change, (10th ed., ). Mason, OH, US: South-Western Cengage Learning.
De Lepeleere, S., Verloigne, M., Brown, H. E., Cardon, G., & De Bourdeaudhuij, I. (2018). Using the intervention mapping protocol to develop an online video intervention for parents to prevent childhood obesity: movie models. Global Health Promotion, 25(2), 56–66 http://dx.doi.org/10.1177/1757975916658603.
Freire, P. (2011). Pedagogia da autonomia: saberes necessários à prática educativa [Pedagogy of Autonomy: knowledge necessary for educational practice]. São Paulo Paz e Terra.
Freire P. (2014). Pedagogia da esperança: um reencontro com a pedagogia do oprimido [Pedagogy of Hope]. São Paulo Paz e Terra.
Freitas, M., & Costa, I. (2018). Grupo de Intervenção Precoce nas Primeiras Crises do Tipo Psicóticas (GIPSI): Acolhendo o Sofrimento Humano [Early Intervention Group for First Episode Psychosis (GIPSI): Accepting Human Suffering]. Revista PsicoFAE: Pluralidades em Saúde Mental, 6(2), 7-14. Retrieved from https://revistapsicofae.fae.edu/psico/article/view/134/72. ISSN 2447-1798.
Gillies, R. M. (2016). Cooperative Learning: Review of Research and Practice. Australian Journal of Teacher Education, 41(3) https://doi.org/10.14221/ajte.2016v41n3.3.
GIPSI (2018). Manual de orientação GIPSI Grupo de Intervenção Precoce nas Primeiras Crises do Tipo Psicótico [GIPSI Early Intervention Group for Early Psychotic Crises Guidance Handbook]. Brasília: Kako Editora.
GIPSI (2019, nov. 11). Grupo de Intervenção [Intervention Group] [Facebook]. https://www.facebook.com/GipsiSempre/.
Grof, S. (1987). Além do cérebro: nascimento, morte e transcendência em psicoterapia [Beyond the Brain: Birth, Death, and Transcendence in Psychotherapy]. São Paulo McGraw-Hill.
Grof, S. (2015). Cura profunda: a perspectiva holotrópica [Deep Healing: the Holotropic perspective]. Rio de Janeiro Numina/Capivara.
Johnson, D. W., Johnson, R. T., & Smith, K. A. (2014). Cooperative learning: Improving university instruction by basing practice on validated theory. Journal on Excellence in University Teaching, 25, 85–118 https://www.researchgate.net/publication/284471328.
Kelder, S., Hoelscher, D., & Perry, C. L. (2015). How individuals, environments and health behaviors interact: social cognitive theory. In K. Glans, B. K. Rimer, & K. Viswanath (Eds.). Health behavior: theory, research, and practice (pp. 159-182). Jossey-Bass.
Köche, J. C. 2016). Fundamentos de metodologia científica [Fundamentals of Scientific Methodology]. Rio de Janeiro Vozes.
Kok, G. (2014). A practical guide to effective behavior change: how to apply theory- and evidence-based behavior change methods in an intervention. The European Health Psychologist, 16(5), 156–170 https://doi.org/10.31234/osf.io/r78wh.
Kok, G., Gottlieb, N. H., Peters, G.-J. Y., Mullen, P. D., Parcel, G. S., Ruiter, R. A. C., … Bartholomew, L. K. (2016). A taxonomy of behavior change methods: an Intervention Mapping approach, Health Psychology. Review, 10(3), 297–312 https://doi.org/10.1080/17437199.2015.1077155.
Kok, G., Peters, L. H. W., & Ruiter, R. A. C. (2017). Planning theory-and evidence-based behavior change intervention: a conceptual review of the intervention mapping protocol. Psicologia: Reflexão e Crítica, 30(19) https://doi.org/10.1186/s41155-017-0072-x.
Lamort-Bouché, M., Sarnin, P., Kok, G., Rouat, S., Péron, J., Letrilliart, L., & Fassier, J. B. (2018). Interventions developed with the Intervention Mapping protocol in the field of cancer: a systematic review. Psycho-oncology, 27(4), 1138–1149 https://doi.org/10.1002/pon.4611.
Lévy, A. (2001). O posicionamento clínico. In A. Levy. Ciências clínicas e organizações sociais: sentido e crise de sentido [Clinical Sciences and Social Organizations: meaning and crisis of meaning]. Belo Horizonte Autêntica/Fumec.
LoBiondo-Wood, G., & Haber, J. (2017). Nursing research-e-book: methods and critical appraisal for evidence-based practice. Missouri: Elsevier Health Sciences.
Lopes, C. B. (2009). Desafios éticos atuais na psiquiatria [Current ethical challenges in psychiatry]. Revista Bioética, 9(1) http://www.revistabioetica.cfm.org.br/index.php/revista_bioetica/article/view/228/229.
Machado, D. M., Moura, A. S. (2016). A utilização de metodologias ativas no ensino do cuidar em saúde [The use of active methodologies in healthcare education]. In F. C. V. França, M. C. Melo, S. N. C. Monteiro, & D. Guilhem. Processo de ensino-aprendizagem de profissionais de saúde – a metodologia por meio do Arco de Maguerez. Brasília: Universidade de Brasília.
Marshall, M., & Rathbone, J. (2011). Early intervention for psychosis. Oxford: Schizophrenia bulletin, 37(6), 1111–1114 https://doi.org/10.1002/14651858.CD004718.pub3.
Ministério da Saúde (2006). Política nacional de humanização [National Humanization Policy]. Brasília: Ministério da Saúde.
Murta, S. G., & Santos, K. B. (2015). Desenvolvimento de programas preventivos e de promoção de saúde mental [Development of preventive programs and of mental health promotion]. In S. G. Murta, C. Leandro-França, K. B. Santos, & L. Polejak (Eds.). Prevenção e promoção em saúde mental: fundamentos, planejamento e estratégias de intervenção (pp. 168-191). Novo Hamburgo: Sinopsys.
Oliveira, P. M. (2011). “É caso para o GIPSI?”: uma etnografia em saúde mental [“Is it a case for GIPSI?”: an ethnography in mental health]. Monografia de Bacharel, Universidade de Brasília, Brasília, DF, Brasil.
Peters, G. Y. (2014). A practical guide to effective behavior change: how to identify what to change in the first place. The European Health Psychologist, 16(5), 142–155 https://doi.org/10.31234/osf.io/hy7mj.
Prochaska, J. O., Redding, C. A., & Evers, K. E. (2015). The transtheoretical model and stages of change. In K. Glans, B. K. Rimer, & K. Viswanath (Eds.) Health behavior: Theory, Research, and practice (pp. 125-148). Jossey-Bass.
Reichert, A., & Jacobs, R. (2018). The impact of waiting time on patient outcomes: evidence from early intervention in psychosis services in England. Health Economics, 27(11), 1772–1787 https://doi.org/10.1002/hec.3800.
Rhinewine, J. P., & Williams, O. J. (2007). Holotropic Breathwork: the potential role of a prolonged, voluntary hyperventilation procedure as an adjunct to psychotherapy. The Journal of Alternative and Complementary Medicine, 13(7), 771–776 https://doi.org/10.1089/acm.2006.6203.
Rohrbach, L. A. (2014). Design of prevention interventions. In Z. Sloboda, & H. Petras (Eds.), Defining prevention science, (pp. 275–292). New York: Springer.
Schaafsma, D., Stoffelen, J. M. T., Kok, G., & Curfs, L. M. G. (2013). Exploring the development of existing sex education programmes for people with intellectual disabilities: An intervention mapping approach. Journal of Applied Research in Intellectual Disabilities: Jarid, 26(2), 157–166 https://doi.org/10.1111/jar.12017.
Schmidt, S. J., Schultze-Lutter, F., Schimmelmann, B. G., Maric, N. P., Salokangas, R. K. R., Riecher-Rossler, A., … Ruhrmann, S. (2015). EPA guidance on the early intervention in clinical high risk states of psychoses. Strasbourg: European Psychiatry Association, 30(3), 388–404 https://doi.org/10.1016/j.eurpsy.2015.01.013.
Severino, Antônio Joaquim (2017). Metodologia do trabalho científico. São Paulo Cortez.
Shorter, E. (2008). History of psychiatry. Current Opinion in Psychiatry, 21(6), 593–597 https://dx.doi.org/10.1097/YCO.0b013e32830aba12.
Stralen, M. M., Kok, G., De Vries, H., Mudde, A. N., Bolman, C., & Lechner, L. (2008). The Active plus protocol: systematic development of two theory- and evidence-based tailored physical activity interventions for the over-fifties. BMC Public Health, 8, 399 https://doi.org/10.1186/1471-2458-8-399.
Suskie, L. (2018). Assessing student learning: A common sense guide. San Francisco, CA: Jossey-Bass.
Svinicki, M., Mckeachie, W. J. (2012). Dicas de ensino: estratégias, pesquisa e teoria para professores universitários [Teaching Tips: strategies, research and theory for university professors]. São Paulo Cengage Learning.
Wetzel, C., Pavani, F. M., Olschowsky, A., & Camatta, M. W. (2017). Avaliação de quarta geração no contexto da reforma psiquiátrica brasileira [Fourth generation evaluation of Brazilian psychiatric reform]. Investigación Cualitativa en Salud, 2, 185–190 https://proceedings.ciaiq.org/index.php/ciaiq2017/article/view/1208.
Ethics approval and consent to participate
The study was approved by the Committee for Ethics in Human and Social Sciences of the University of Brasília under the opinion of No. 2,927,033, of September 28, 2018. All participants were properly informed of their rights. Informed consent forms were signed by those who agreed to participate.
Consent for publication
The authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.
About this article
Cite this article
Machado, D.M., Murta, S.G. & da Costa, I.I. Applying intervention mapping approach to a program for early intervention in first-episode mental crisis of a psychotic type. Psicol. Refl. Crít. 33, 3 (2020). https://doi.org/10.1186/s41155-020-00141-0
- Intervention mapping protocol
- Mental health
- Non-ordinary states of consciousness
- Intervention in crisis