Cognitively Oriented Psychotherapy for First-episode Psychosis (COPE)

A Practitioners Manual

Manual 4 in a series of Early Psychosis Manuals

Cognitively Oriented Psychotherapy for First Episode Psychosis (COPE): A Practitioners Manual
Lisa Henry, Jane Edwards, Henry Jackson, Carol Hulbert, Patrick McGorry
Published by EPPIC: the Early Psychosis Prevention and Intervention Centre.

 EPPIC, 2002 Reprinted 2006, 2007 ORYGEN Research Centre (Incorporates EPPIC) Early Psychosis Prevention and Intervention Centre Locked Bag 10 Parkville, Victoria 3052 <www.eppic.org.au> <www.orygen.org.au>

ISBN 1-920718-01-X

Suggested citation:
Henry, L., Edwards, J., Jackson, H., Hulbert, C., McGorry, P. (2002). Cognitively Oriented Psychotherapy for First Episode Psychosis (COPE): A Practitioners Manual. Melbourne: EPPIC.

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CONTENTS
Acknowledgements ................................................................................................iv Preface .................................................................................................................v How to use this manual .........................................................................................vi

PART 1: THEORY
1. 2. 3. Need for new forms of psychotherapy in early psychosis ...................................... 1 Emergence of cognitive approaches to therapy in psychosis ................................. 3 Applications of cognitive therapy ..................................................................... 4 3.1 3.2 3.3 3.4 4. 4.1 4.2 4.3 4.4 Cognitive remediation ........................................................................... 4 Reducing positive psychotic symptoms and associated distress .................... 5 Co-morbidity ........................................................................................ 5 Psychological vulnerability ..................................................................... 6 Constructivism .................................................................................... 8 Crisis, disaster and trauma theory ........................................................... 9 Attribution theory ...............................................................................10 Developmental theory ..........................................................................11

The self and psychosis ................................................................................... 8

PART 2: PRACTICE
1. 2. Introduction .................................................................................................13 Assessment ..................................................................................................15 2.1 2.2 2.3 3. 3.1 3.2 4. 4.1 4.2 4.3 4.4 5. 5.1 5.2 6. 6.1 6.2 Psychological assessment......................................................................15 Strategies and techniques .....................................................................18 Determining the agenda for therapy .......................................................21 Developing and maintaining the therapeutic alliance ................................24 Barriers to engagement ........................................................................27 Psychoeducation..................................................................................31 Vulnerabilitystress model ....................................................................36 Identity work ......................................................................................39 Coping enhancement ............................................................................43 Assessment .........................................................................................45 Strategies and techniques .....................................................................46 Reinforcement .....................................................................................54 Relapse management and prevention ......................................................55

The therapeutic alliance .................................................................................23

Adaptation ...................................................................................................29

Secondary morbidity ......................................................................................45

Reviewing therapy before completion ...............................................................54

References ..........................................................................................................57

ACKNOWLEDGEMENTS

The COPE project would not have been possible without the input, work and dedication of the following people and organisations: Professor Patrick McGorry; Associate-Professor Henry Jackson; Dr Jane Edwards; and Dr Carol Hulbert, who initiated the concept; and Ms Lisa Henry; Ms Shona Francey; Ms Dana Maude; Dr-Paddy-Power; and Dr-John Cocks; a team of therapists who contributed to development of the COPE intervention; and the Victorian Health Promotion Foundation, which sponsored the Early Psychosis Project. We thank you for your support and input.

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PREFACE

In this manual, we aim to assist mental-health clinicians in providing optimal care for young people who have emergent psychosis. The evolution of Cognitively Oriented Psychotherapy for Early Psychosis (COPE) was based on 10 years of clinical experience who had clients with firstepisode psychosis, and on the theory and practice described in the literature about cognitivebehavioural psychotherapy (CBT). The aim of COPE is to facilitate recovery from a first episode of psychosis, and COPE is one component of a biopsychosocial approach to treatment. COPE was developed at the Early Psychosis Prevention and Intervention Centre (EPPIC) by a team of specialist clinicians and researchers (psychologists and psychiatrists). EPPIC provides a specialist, comprehensive early-intervention program for young people who have psychosis and are living in the western region of Melbourne, Victoria. The program accepts young people aged 15 to 29 years who are experiencing their first treated episode of psychosis (people who have received more than six months of pharmacological treatment for psychosis in the past are referred elsewhere). Treatment at EPPIC typically spans 18 months. For clients who enter the program at age 15 or 16, treatment can be extended until they reach 18. EPPIC was founded on the premise that best practice for later stages of psychosis, when clients can be more persistently ill and disabled, might not constitute best practice for early psychosis. This premise led to development of a specialised clinical model for young people experiencing a first episode of psychosis. EPPIC programs have achieved a significant reduction in the disability and disruption traditionally associated with psychotic disorders (McGorry et al., 1996).

HOW TO USE THIS MANUAL

In this manual, we provide a set of theoretical principles, then link them to guidelines and therapeutic techniques for working with young people who are recovering from an initial episode of psychotic illness. We illustrate how a cognitivetherapeutic approach, enriched by other relevant perspectives and therapeutic strategies, can be adapted to the special issues faced by patients recovering from a recent onset of psychosis. The model is one component of a broader biopsychosocial approach, and is designed to be used by clinicians who have a comprehensive knowledge of psychosis. This manual will be a useful supplement to ongoing supervision, peer support or professional consultation for clinicians wishing to apply their existing CBT skills to first-episode patients. Clinicians who are interested in embarking on CBT will find it to be a useful resource after they have completed their initial training. The manual is structured in two parts: theory and practice. In the first part, we provide a theoretical context for the evolution of COPE: we do not intend to provide a comprehensive introduction to either psychotherapy or early psychosis. The second part is a structured overview of the four focuses of COPE: assessment, the therapeutic alliance, promotion of an adaptive style of recovery, and prevention or management of secondary morbidity. We detail effective strategies for working therapeutically on each focus, including techniques for working with people for whom it is difficult to use therapy. The practical part of the manual has been designed so that clinicians can dip into sections and move between them, not necessarily in a linear way, depending on the needs of individual clients.

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PART 1: THEORY
1. Need for new forms of psychotherapy in early psychosis

The following two quotes are a succinct description of the COPE philosophy. It is worth trying to help schizophrenics. The recognition that in the schizophrenic a hidden normal psychic life continues behind the psychotic facade must encourage us to care for him. Bleuler (1979) Now that the biological revolution is in ascendancy, we need to step back and reflect on what a biologically based distortion of the human spirit means for the person who suffers it, and for the interventions required. In our rush to discover the basic biology of schizophrenia, we have ignored the human experience of schizophrenia...I would suggest that we now need to rebuild a biologically sound, problem-specific approach to psychotherapy with schizophrenia that is grounded in the human experience of the disorder. Coursey (1989) In recent years, there has been a resurgence of interest in the individual psychology and psychotherapy of psychotic disorders, particularly schizophrenia. Psychodynamically oriented psychotherapy was the dominant therapeutic approach for psychosis in the 1950s. Enthusiasm for this approach to schizophrenia quickly waned, probably due to two influences: First, the 1950s included successful introduction of neuroleptic medication and a tendency to consider psychotherapeutic approaches as an alternative rather than as a complementary therapy. Second, an empirical study was published in which it was concluded that psychodynamically oriented psychotherapy was comparatively ineffective in treating people suffering from schizophrenia (May, 1968; Gunderson et al., 1984). The findings of Gunderson et al. (1984) were the rationale for considering other theoretical bases for the intervention and its role in treating schizophrenia, and resulted in virtual disappearance of psychodynamic therapy in psychotic disorders.

Need for new forms of psychotherapy in early psychosis

The report from Gunderson et al. also prompted emergence of the regrettable phenomenon of the 15-minute outpatient-clinic review, which entailed assessment of the patients mental state and prescription of medication, but little else. This phenomenon might have partly reflected a lack of guidance for clinicians about what else they might be able to do. The 1960s through to the 1980s included emergence of the behavioural paradigm and its application to the problems of psychiatric patients. The major criticism of this approach was its poor generalisation to real-life community settings and the instability of maintenance effects (Hayes & Halford, 1993). In addition, rehabilitation programs involved a narrow behavioural approach in which potentially helpful interventions were packaged and prescribed to relatively passive patients. The individual psychology and experience of the sufferer were neglected (Strauss, 1994). There were a range of reasons for this approach, but a critical factor was the lack of a strong theoretical base and a related set of therapeutic strategies to inform collaborative psychotherapeutic work. The past 15 years have included seen an expansion of cognitivebehavioural therapeutic approaches in treatment of people who have schizophrenia. The focus has been on a number of aspects of the disorder, and have been positive results. They include family interventions (Barrowclough and Tarrier, 1992, 1994; Mueser et al. 1994); family and social-skills interventions (Falloon, 1985; Hayes & Halford, 1993; Scott & Dixon, 1995); relapse prevention (Birchwood; 1992) and reduction in psychotic symptoms (Kingdon and Turkington, 1991).

Part 1: Theory

2. Emergence of cognitive approaches to therapy in psychosis

As a result of a decline of psychoanalytic therapy in general, and in the care of psychotic patients in particular, clinicians were left to consider alternative psychotherapeutic paradigms to fill the gap. In interventions that were derived from traditional behavioural therapy and that where applied in rehabilitation programs, clinicians failed to directly address the internal world of the person, and the gap remained. Alternatives include modified or hybrid theories and therapies that emerged from a synthesis of the classical approaches and through which new principles and techniques were created. These can be collectively termed cognitively oriented therapies although many other aspects of psychological functioning, notably emotion (Perris, 1989), are addressed in them. These therapies are now a highly influential and promising force in psychotherapy theory and practice. In many psychiatric disorders, especially depression and anxiety, cognitive therapy has been shown to be effective in its own right and when used to complement medication (Beck et al., 1979; Andrews et al., 1994). Several groups have recently begun to apply cognitive strategies for patients who have psychoses, mainly schizophrenia. The focus of the interventions has been on: cognitive-remediation and information-processing deficits treatment of positive symptoms secondary morbidity associated with psychosis general psychological vulnerability to psychosis impact of the disorder on the person and the adaptation of the self in the wake of a psychotic disorder.

3. Applications of cognitive therapy

3.1 Cognitive remediation

Cognitive remediation is an emerging focus in rehabilitation, based on findings that cognitive deficits are often a fundamental aspect of persistent or residual symptoms in schizophrenia. The field is in its infancy, and there have been some cautious or even sceptical responses (Bellack, 1992; Hogarty & Flesher, 1992). Approaches include strategies targeted at the specific cognitive impairments or the behavioural correlates of these impairments (for example poor social skills). Most effort to date has been applied to specific cognitive impairments, whereby intensive training and other strategies have been attempted. Interventions have been based on the model of neuropsychological rehabilitation following a closed-head injury, despite reservations about the models relevance to psychosis. Brenner et al. (1992) supplemented this approach in a phase-oriented way with higherlevel cognitivebehavioural interventions or sub-programs in a package known as integrated psychological therapy (IPT). The efficacy of this technique has yet to be demonstrated in controlled clinical trials. However, it is apparent that these approaches are likely to be most relevant for the sub-group of patients who have persistent cognitive and related deficits following an acute - psychotic episode. Cognitive impairments feature prominently in individuals who are vulnerable to psychotic episodes, and dominate the acute psychotic phase in many cases, thereby providing an additional rationale for cognitive approaches in treatment of psychosis. There have been attempts at cognitive remediation or rehabilitation (Kingdon & Turkington, 1991; Spring & Ravdin, 1992; Brenner et al., 1992) directed at problems with information processing as well as core symptomatology. This is more akin to treatment and rehabilitation in a narrower sense, and is distinguished from pure psychotherapy because the focus is on the impairment or deficit rather than on the person and his or her response.

3.2 Reducing positive psychotic symptoms and associated distress

The standard biological treatment for patients presenting with psychotic symptoms is to prescribe neuroleptic medication. Neuroleptics have led to a revolution in the treatment of psychosis, but there is still a proportion of patients in whom psychotic symptoms persist despite appropriate medication. More recently, cognitive and behavioural interventions have been used to reduce or suppress the level of positive psychotic symptoms, particularly delusions and hallucinations, and/or the distress associated with experiencing these symptoms. Work in this area began with Arieti (1979), who modified the psychoanalytic approach to help patients identify psychological states of mind that were precursors to frank psychotic experiences. He described these mental states as referential or listening attitudes when the patient would be vulnerable to experiencing specific psychotic symptoms. He suggested that patients could learn to recognise these warning signals and to handle them in a way that interrupted the sequence. Other researchers have examined the cognitive and behavioural strategies discovered by patients to cope with persistent psychotic symptoms (Falloon & Talbot, 1981; Breier & Strauss, 1984; Carr, 1988). There has been a concerted effort to evaluate the interventions, and favourable outcomes from family interventions (Barrowclough & Tarrier, 1992), early intervention and monitoring of prodromal signs (Birchwood, 1996), and psychological treatments to reduce the occurrence and distress associated with persistent positive symptoms (Sellwood et al., 1994). Various theories have developed in which researchers have examined either a cognitive model of delusions and auditory hallucinations (Chadwick et al. 1996) or behavioural coping strategies, in both of which the aim is to directly suppress or attenuate positive symptoms (Birchwood & Tarrier, 1992). There have been some encouraging findings, but more development and evaluation are essential. These strategies have great potential value for patients who, despite adequate medication, experience persistent positive symptoms that persist beyond the acute episodes of their illness.

3.3 Co-morbidity
Psychiatric co-morbidity, defined as presence of a psychiatric syndrome in addition to the main diagnosis, has attracted increasing attention over the past decade. Its importance in terms of diagnosis, treatment and prognosis has now been recognised. If two disorders occur simultaneously, questions are raised about whether they should be considered as separate conditions. Presence of two or more disorders can result in clouding the clinical picture and diagnosis can be made more difficult. Co-morbidity can result in modification of response to treatment or necessitate multiple treatments. Patients who have co-morbidity often have a worse prognosis than do patients who do not have co-morbid conditions, because they carry the risks of two disorders in addition to the risk of any interaction between the disorders. In schizophrenia, presence of co-morbid symptoms and syndromes has been well documented. Substance abuse is a common co-morbidity, and can involve abuse of alcohol, stimulants, benzodiazepines, hallucinogens, anti-Parkinsonian drugs, caffeine and tobacco (Lohr & Flynn, 1992). Mathers and Ghodse (1992) hypothesised that cannabis use exacerbated the symptoms of schizophrenia. In the World Health Organizations

Applications of cognitive therapy

10-country longitudinal schizophrenia follow-up study, cannabis use was a predictor of poor outcome at two years in a patient who had with recent-onset schizophrenia. Researchers in many studies have reported varying prevalence rates for depression in people who have schizophrenia (McGlashan & Carpenter, 1976; Siris, 1991; Bermanzohn & Siris, 1992). The rate of depression has ranged from 7% to 75%. In The Chestnut Lodge study by Fenton and McGlashan (1986), it was found that 13% of people who had schizophrenia had obsessive-compulsive behaviours. The frequency of panic attacks in people who have schizophrenia is reported to be between 28% and 63% (Boyd, 1986; Argyle, 1990). Due to the broad range of prevalence rates reported for co-morbid disorders, a measure of uncertainty is suggested, which can be explained by referring to the following factors: In current diagnostic practice, a hierarchical approach is promoted that can result in leaving co-morbid and secondary disorders undiagnosed and untreated. The psychotic symptoms can cloud or confuse the co-morbid disorder; for example, depression can be dismissed as negative symptoms. Bermanzohn et al., (1997) suggested that the term associated psychiatric syndromes be used instead. Side effects from antipsychotic medications can resemble disorders such as anxiety and depression.

Presence of a co-morbid disorder in psychotic disorders can affect the outcome, or act as a trigger or stressor to induce a psychotic disorder in predisposed individuals (Zubin & Spring., 1977). Strakowski et al., (1995) found that co-morbidity was present before the first episode of psychosis in 80% of patients who had concurrent psychiatric syndromes. It is therfore suggested that treating the co-morbid disorder is as important as treating the main psychiatric disorder. Treatment of co-morbidity can require a wide repertoire of cognitive and behavioural strategies. In treating specific secondary conditions, clinicians should make use of interventions that have established efficacy (Jackson et al., 2000). Evidence-based clinical research supports use of cognitivebehavioural therapy for depression and anxiety disorders (DeRubeis & Crits-Christoph, 1988).

3.4 Psychological vulnerability

In the vulnerabilitystress model (Zubin & Spring, 1977), a useful and practical summary is provided of the factors that can be involved in development of psychotic illness. According to this model, the likelihood of developing a psychotic illness depends on: the degree of vulnerability a person brings to a situation (for example biological, personality or neurological impairment) exposure to a range of additional stress, such as life events (for example marrying, leaving home, starting work or grieving) and environmental influences (for example relationship problems or conflict at work).

This concept of vulnerability to psychosis can be extended to include vulnerability to a wider range of psychological problems. It also embraces the notion that people who have pre-morbid vulnerability will be more likely to develop post-psychotic or secondary morbidity of various kinds, and be more at risk of frank psychotic relapse.

Part 1: Theory

Pre-morbid vulnerability can be thought of in a number of ways. There can be: compromise in information processing a feature evident in many studies into the risk of psychosis identifiable psychological problems such as low self-esteem or a vulnerability to pathological cognitive styles (for example depressive cognitions in the absence of a depressive disorder) specific developmental trauma or other factors through which a specific vulnerability is conferred, representing a psychological Achilles heel that might be understood best from a psychodynamic perspective.

The latter two contributors to vulnerability are potential targets for preventively oriented psychotherapy in the recovery phase of a psychotic episode, before emergence of any frank post-psychotic secondary morbidity such as depression.

Applications of cognitive therapy

4. The self and psychosis

4.1 Constructivism
Perris (1989) noted that two views of human nature underlie most psychotherapeutic theories. The first is that people are pilots, responsible for the direction of their lives. The second is that people are robots and not responsible for the course they follow. Most cognitive theorists adhere to the first view. In constructivism, the view has developed that people are scientists who continuously form and revise hypotheses about all aspects of their lives, selves and environment (Kelly, 1955). This is expressed in personal-construct psychology, a theory developed by Kelly (1955). The theory has given rise to a psychotherapeutic approach centred around the patients systems of meaning. Mahoney and Lyddon (1988) described constructivism as follows. The constructivist perspective is founded on the idea that humans actively create and construe their personal realities. The basic assertion of constructivism is that each individual creates his or her representational model of the world. This experiential scaffolding of structural relations in turn becomes a framework from which the individual orders and assigns meaning to new experience. As young people enter treatment for the acute symptoms of psychosis, they have to relate the experience of becoming a patient to their existing scaffolding of meaning. During the acute phases of illness, the scaffolding can be partly or seriously rearranged, and thereby be functioning in a different and inefficient way (Bannister, 1962). This is less of an issue during and following recovery when psychotherapy becomes a possibility especially if recovery is substantial. The normal psychic life referred to by Bleuler is then involved in a process of reconstruing the experience of psychosis and treatment in relation to its established construct systems.

4.2 Crisis, disaster and trauma theory

Crisis, disaster and trauma are three related areas that are a rich theoretical and practical basis for preventively oriented therapy among survivors who are in the early stages of a psychotic disorder. There is little doubt that the onset of a psychotic illness, particularly if acute, represents a major crisis for the individual and the family and that it can overload coping resources (Jeffries, 1977; Jones et al. 1986). The term disaster is used to denote overwhelming events and circumstances through which the adaptational responses of a community or individual are tested beyond their capability and lead to massive disruption of function. Disastrous events give rise to a range of outcomes, including loss and trauma, which in turn can result in psychological morbidity. Psychological trauma is a concept that has greater specificity. According to McCann and Pearlman (1990), an experience is traumatic if it is sudden, unexpected or nonnormative; exceeds the individuals perceived ability to meet its demands; and disrupts the individuals frame of reference and other central psychological needs and related schemes. Figley and Southerly (1980) defined trauma as a response that represents an emotional state of discomfort and stress resulting from memories of extraordinary, catastrophic experience which shattered the survivors sense of invulnerability to harm. The overlapping concepts of crisis, disaster and trauma are associated with a natural process of homeostasis, regeneration and recovery. There is tremendous scope for preventively oriented strategies for patients recovering from their first psychotic episode, before development of enduring secondary morbidity. Management of the acute and recovery phases of the first episode, by both the patient and significant others, influences the subsequent course and nature of the illness (Ciompi, 1988). Doane et al. (1991) state that we should treat the initial episode of schizophrenia as a traumatic event and apply intensive, focused treatment interventions to the patient and his or her family to minimise the trauma. Trauma in the setting of early psychosis Emergence of a psychotic disorder, entry into treatment and being labelled as mentally ill are generally (but not always) traumatic experiences. These experiences can have a major disruptive effect on the cognitive schemas of the individual. Horowitz (1986) described person schemas that involve enduring but slowly changing views of self and of other, and with scripts for transactions between self and other. Each individual can have a repertoire of self schemas, but when a traumatic event occurs, there might not be an appropriate schema available for adapting to the event. Schematic change occurs by evolution, not by erasure of existing schemas. Enduring schemas might have been fundamentally challenged or even shattered through the first experience of mental illness, thereby leading to extreme and often maladaptive coping measures such as denial. Jeffries (1977) and Stampfer (1990) proposed that some of the negative symptomatology in schizophrenia can be a consequence of an avoidance response or a generalised psychic numbing due to trauma. McGorry et al. (1991) showed a tendency for negative symptoms to increase over time in patients who met the criteria for both post-traumatic stress disorder (PTSD) and psychosis. Negative symptoms have multiple possible determinants, and are less stable and more reversible in early psychosis compared with later in the illness (Kay et al. 1989; McGlashan & Fenton, 1992). A role for preventively oriented therapies is therefore suggested, whereby the focus is on the traumatic experience of psychosis, and the aim is prevention or dissolving the numbing and avoidant responses that can contribute to negative symptoms.

The self and psychosis

The trauma of psychosis in late adolescence or early adulthood occurs at a critical time for identity formation and development of intimacy. Any major Axis I disorder that has its onset at this phase of the life cycle has the capacity to result in a disorder of personality functioning (Bronisch & Klerman, 1991). In his work with Vietnam veterans, Wilson (1988) observed that trauma could impact on normal personality patterns and result in transformation of them in pathological directions such as schizotypal, paranoid or borderline, depending on the pre-trauma personality and stage of ego development. The influensce of the post-traumatic environment in shaping the survivors response is well recognised. In psychotic illness, there can be a perception that the community will respond critically and intolerably. Moreover, before the onset of illness patients often have a set of stigmatising attitudes about mental illness, thereby forming a schema that becomes resistant to change. The trauma model is a useful framework for understanding the impact of societal attitudes on the recovering individual. Implications for therapy McCann and Pearlman (1990) suggested a range of strategies that can be adapted to the post-psychotic period. In their model, they blended developmental psychology, self theory/constructivism and cognitive theory in a way that lends itself naturally to the recovery process in early psychosis. In interventions following trauma, the aim is to: promote a sense of mastery of the experience promote support from significant members of the social group facilitate working through the traumatic experience and the emotions of fear, helplessness, anxiety and depression.

Taylor (1983) presented a theory of cognitive adaptation to threatening events whereby the focus was on the self-curing abilities of individuals. In this theory, three themes are suggested around which the readjustment process is focused: A search for meaning in the experience An attempt to regain mastery over the event in particular and over ones life more generally An effort to raise ones self esteem to feel good about oneself again despite the personal setback

Taylor contended that successful completion of these tasks depends on ability to form and maintain a set of illusions that are essential to normal cognitive functioning. This can represent a challenge to many mental-health clinicians, who tend to assume that positive mental functioning depends on being in touch with reality. The implications for therapy are that three themes of readjustment will be relevant to patients, and that illusion should be accorded respect and fostered rather than stripped away.

4.3 Attribution theory

Attribution theory can be used to help understand the normative attributions that patients and mental-health clinicians hold in relation to emergence of a psychotic disorder. The theory includes the suggestion that:

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Part 1: Theory

attributions will differ between the person (or actor) and the clinician or family members (observers) attributions will change from the early stages of the disorder to later in the course of the illness a number of factors will influence attributions some attributions will be either protective or damaging to self-esteem.

In the last point, a link is formed with the abovementioned more general notion of cognitive biases. It is important with reference to therapeutic strategies in relation to attribution, and their meaning in the short and longer term.

4.4 Developmental theory

Developmental psychology Most psychotic disorders emerge during adolescence and young adulthood. There are a number of key developmental tasks facing the individual at this time that are profoundly affected by the onset of illness. Adolescence is a transitional period that involves a complex series of psychological and sociocultural events and influences that contribute to development of an independently functioning person. Cognitive development Cognitive processes develop during adolescence from a child-like, concrete, structured framework to a more abstract framework. The adolescent develops the capacity to think about propositions and possibilities he or she has never concretely experienced. This is what Piaget (Ginsburg & Opper, 1969) termed formal operations, which is the ability to think more abstractly, using deductive as well as inductive logic, and approaching decisions and problems in a systematic way. Psychological development Adolescence involves development of an autonomous person who is no longer dependent on other people for management of thoughts and behaviour. This idea was embraced by Erikson (1968), who suggested that the goal of psychological development was development of a mature sense of identity that occurs through interpersonal processes. Erikson developed eight psychosocial stages from birth to middle age, thereby suggesting that each person moves through a fixed sequence of tasks or dilemmas during these stages. In adolescence, the main task is formation of an ego identity a sense of self as separate from other peoples and capacity to regulate internal and external events in the move towards life goals. The psychosocial process of adolescence involves three major tasks, which can extend into adulthood: Moving from being a dependent person to being an independent person Establishing an identity Learning to relate intimately with other people.

Dependency to independence Adolescents might need to reject their parents values and reformulate their own value systems as they gain independence. This time can be volatile because adolescents are

The self and psychosis

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constantly testing values, challenging the contradictions in their parents values, and assessing the worth of alternative ideals and rules. Adolescents select values from various sources in the process of determining their own. Identity Older adolescents look to other people in their environment and blend some of these other peoples personality features with their own to develop a new identity. This identity is shaped throughout life as roles change, for example adjusting to becoming a spouse, parent or worker. Outside forces such as peers, and the persons culture and family, also play a significant part in shaping identity. If adolescents successfully master this stage, they will have a functional identity, and healthy and positive feelings about themselves. Intimacy Intimacy is defined as successfully being able to relate to other people and eventually to one other person as equals on a one-to-one basis. Development of intimacy commences in late adolescence and continues into young adulthood. Successful development of intimacy is reflected in establishment of relationships in which each person needs the other for emotional well-being yet can still function independently (Erikson, 1968). The peer group During adolescence, the importance of the family is replaced by select institutions such as the peer group and the school. The adolescent normally draws away from the sphere of influence of the parents in the process of individuation that is essential to identity formation. The peer group is a vital agency for social growth and change in which the adolescent, for the first time, experiences significant relationships that lack the familiarity and security of those with the family. The peer group presents the challenging opportunity for adolescents to shape their identity by confronting questions such as How do I fit in? What roles will I play? What if Im not accepted? How can I change this? The young person recovering from psychosis Onset of psychosis disrupts the psychological development of an adolescent or a young adult. At a time when peers are testing and achieving their independence, the young person recovering from psychosis is being monitored and treated by a range of health professionals. The family becomes a dependable, secure environment for recovery. Vocational or study opportunities are either lost or delayed. As a result of the illness, the young person can experience difficulties relating to, and re-integrating with, the peer group. The experience of psychosis, the treatment process and the response from the post-psychotic environment can disrupt the formation of the adolescents newly emerging self identity. The outcome could be one of low self-esteem, anxiety or depression, resulting in a dysfunctional, negative identity. The post-psychotic adolescent can experience difficulties relating to the previous peer group. Questions arise such as Where do I now fit in with my old group? The concern is that the answer might be I dont. Problems can arise if the post-psychotic adolescent starts to identify with people who are sick and dependent.

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Part 1: Theory

PART 2: PRACTICE
1. Introduction

COPE is a focal approach to management of older adolescents and young adults experiencing their first episode of psychosis. The therapy has four goals as follows. 1. To assess and understand the patients explanation of his or her disorder and gain an appreciation of the patients attitude towards psychosis in general. This involves identifying the persons current and potential problems, and formulation of factors contributing to their cause and maintenance. These factors include strengths, weaknesses, coping style, resources available, and patients perspectives for considering their problems 2. To engage with the patient and develop a therapeutic relationship in order to form a collaborative therapeutic framework 3. To promote a style of adaptive recovery from psychosis. Recovery is achieved by focusing on how the person is adjusting to the reality of experiencing a psychotic episode, the possibility of an ongoing vulnerability or continuation of symptoms, and how the patient perceives himself or herself now. The therapist might offer a new model of the patients experiences and judgements about psychosis. The vulnerabilitystress model is used, together with cognitive clarification, depending on the patients willingness to consider another perspective. The aim is to decrease distress and promote an adaptive response 4. To prevent or manage secondary morbidity that has developed subsequent to the psychotic disorder, such as depression, anxiety and stigma, which can influence self-esteem These goals of therapy are not necessarily discrete; nor do they represent an inevitably unfolding sequence. In practice, there is overlap, whereby shifts occurr from one goal to another; however, for the sake of clarity, they will be presented as discrete goals. Consistent with the cognitivebehavioural therapy approach, therapy is carefully tailored to each individual, based on the therapeutic formulation of the problem. Therapy is offered to patients towards the end of the acute phase of the psychotic disorder, when the mental state has stabilised, and the patient is more likely to be responsive and ready

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to engage in therapy. Therapy can also be introduced after a relapse has occurred whereby the person might be psychologically ready for therapy. The number of sessions and length of time required for therapy will depend on a number of factors, including the strength of the therapeutic alliance (and therefore the commitment of the patient to enter and participate in therapy) and the severity and complexity of the problems presented. Our experience is based on programs of 20 and 30 sessions.

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Part 2: Practice

2.

Assessment

In this section, we describe the therapy-assessment phase and discuss the importance of developing a therapy agenda. Techniques and strategies that have proved useful at this phase of therapy are outlined. Recommendations are provided for problems encountered in therapy at this initial stage. The formal-assessment phase is succinct, and information can usually be gathered within three therapy sessions.

2.1 Psychological assessment

Psychological assessment occurs at the point of first contact with the patient during recovery following an acute episode of psychosis. The goals are to engage the patient in therapy and to undertake a concise assessment. To engage the patient is to develop a therapeutic alliance, or a supportive working relationship in which trust can develop. More detail about the therapeutic alliance is contained in Section 3. Based on the following model, a succinct assessment takes a skilled clinician approximately three sessions. The basis of the procedure is to assess the persons understanding and explanation for his or her experiences, and his or her ideas about the consequences of a psychotic episode. The first session is introductory, in which the patient is provided with a rationale for therapy and for the assessment process.

Case example Therapist: Sometimes, people who have had a similar experience to yours are confused and have many queries about the experience. So, maybe this is a time for you and me to sort out your concerns, so youre able to understand your experience and sort out any problems it might have caused you. Okay.

Patient:

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Therapist:

Initially, this involves developing an understanding of what was going on in your life around the time you became unwell, and your thoughts and feelings about that. So, for about the next three sessions, well look at this time in more detail. Ill also ask you some questions about your lifestyle, which will include job/school, family, friends and your hobbies, so I can understand you better. I cant remember too much, though. Thats absolutely normal for you to have difficulty remembering some events. If you wish, well go over events to help prompt your memory. Then well define together an agenda or a list of things you want to discuss during this time. From this list, we will choose what well discuss each week. How does this sound to you? Okay.

Patient: Therapist:

Patient:

In the assessment, the aim is to elicit specific information from the patient in order to reach a formulation through which the therapeutic approach will be guided. The therapist must be alert to: the current stage in the acuterecovery phase the presence of positive, negative, depressive or manic symptoms the current adaptation style and explanatory model the presence of secondary and/or co-morbidity symptoms the extent of trauma and loss the extent and content of knowledge about psychosis the personality structure previous therapeutic contact the level of current cognitive impairment (attention, concentration and memory) the sociocultural and religious context.

In Table 1, we outline questions and prompts through which the therapist can be helped in assessing these issues, and the patient can be helped with disclosure.

Table 1 Assessment
Explanatory model How does the patient explain his/her mental illness? What is his or her theory? What was the meaning of the psychosis for the patient? What does the patient understand his or her illness to be? What does he or she call it? Does he or she have control over it? Why did this happen to him or her? Why at this time in his or her life?

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Psychoeducation How does the person define psychosis? What does he or she think it is, and where does it come from? Why does he or she think it happened to him or her? What knowledge does the patient have about mental illness? Was there a stressor that precipitated the patients admission or psychotic episode? What was going on in the patients life before the psychotic episode? What were the early-warning signs? How can relapse be prevented? Where does he or she believe himself or herself to be within the episode, that is, acuterecovery? What does he or she anticipate his or her recovery will be like? Adaptationidentity How does the patients perception of being psychotic impact on his or her life and lifestyle? How does the patient view himself or herself now? How does the patient think other people view him or her? Do people treat or behave differently towards him or her now? What was the patients perception of his or her future before becoming psychotic? What perception does the patient have now of his or her future? Has it changed? Why has it changed? Does the patient believe himself or herself to be well? Does the patient believe he or she was ever unwell? How does the patient plan to stay well? What are his or her coping strategies? Does the patient believe he or she has some control over his or her psychosis? Secondary morbidity Does the patient have times when he or she feels depressed or anxious? How does he or she react when this happens to him or her? How does the patient cope with negative mood states? What is the meaning of being depressed or anxious for the patient? How does the depression, anxiety and so on interfere in the patients life? Trauma and loss Did the patient experience the psychosis as being traumatic? How does the patient cope with the impact of hospitalisation, the psychotic episode or relapse? Was there anything related to the psychosis, but not the psychosis itself, that was considered traumatic? Has the patients social, domestic and professional situation changed after his or her having been psychotic? Is there anything the patient avoids because it reminds him or her of being psychotic?

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Personality issues How does the patient describe his or her personality? Does the patient think he or she is different from how he or she was before he or she became unwell? How does the patients family and friends describe his or her personality? Does the patient exhibit dependent, avoidance, schizoid, histrionic or borderline personality traits? How does personality and intellectual level impact on the patients ability to cope? Therapeutic contract What does the patient want from therapy? What is his or her perception of the therapists role? Has he or she seen a therapist before? If so, what were these experiences like? Does he or she understand the role of time-limited therapy? In addition, a thorough developmental and personal history has to be gathered, using a standard protocol for taking a psychosocial history.

2.2 Strategies and techniques

The therapist should aim to put the patient at ease and convey understanding from the first interview onwards. The patient usually has no knowledge of the therapeutic process or situation. It is the therapists job to convey an understanding of the patients doubts and concerns, and an intention to help him or her. There are a number of strategies to initiate rapport and enable the patient to freely self-disclose. For example, it is important to provide a clear and understandable rationale for meeting with a therapist. The therapist should acknowledge and understand the possible trauma of the patients recent experience of psychosis and its consequences, the impact of this experience, and current difficulties. The therapist should carefully consider past and existing developmental and personality factors, bearing in mind the impact of the psychosis on the current phase of development and the prominence of adolescent issues in this patient group. In the initial engagement, a warm, empathic style is required. Difficulties can arise in the engagement process if the therapist is perceived as being an authoritarian figure. It is important to give patients confidence in ones understanding of their problems without seeming to be rigid or commanding. First, describe the general goals of therapy; then, elicit the patients expectations for it. Some helpful prompts include: Is there anything I could help you with? Do you have any problems that have to be dealt with straight away? What do you think youd be doing if you were better? If we are able to work together to help you solve your concerns, how do you think life will be in a few months?

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Depending on the stage of recovery and cognitive ability, ask the patient to write a few paragraphs as a homework assignment, addressing the following questions. What was your experience in hospital like? What was your experience of being unwell like? Why do you think this happened to you at this point in your life? How has it affected you? Has it changed you? If so, how?

This questioning can be attempted during the session if the patient is reluctant to do it at home. It is interesting to see what patients write when they have time to reflect and to ask their family and friends for input. Referring to answers to these questions is useful in formulating a picture of the person and in developing a working agenda for therapy.

Case example Alice, 25, deferred her university course because of her psychotic illness. She initially engaged well with her therapist but later started to arrive late or not attend. This is how the therapist approached the problem. Therapist: Alice, it seems youve been having difficulty arriving at our sessions on time... So? Could it be that its difficult for you to be here? What do you mean? Well, could it be that youre currently having a difficult time? For sure! Would you like to tell me about that? Well, I cant stand being around my friends. Why is it difficult being with your friends? Theyre at university and Im left out! This must be difficult and sad for you. How have you been left out of things?

Alice: Therapist: Alice: Therapist: Alice: Therapist: Alice: Therapist: Alice: Therapist:

Here, the therapist is demonstrating sensitivity and is able to empathise with Alice by discussing, indirectly, the possible problems she is experiencing. This helps reduce the authoritarian know-all standpoint.

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It can take a considerable amount of time for both the patient and the therapist to come to a shared understanding of the purpose of therapy. This rationale can be reviewed and renegotiated, depending on the needs of the patient. Placing emphasis on a collaborative approach to the engagement process is usually the most successful strategy. For example, the therapist might choose to familiarise the patient with the workings of the mental-health system in a collaborative way whereby he or she draws on the patients experience and directly accesses the people the patient was involved with. The patient is thereby empowered and an image is presented of the useful therapist, whereby formation of a therapeutic alliance is made easier.

Case example A collaborative approach Mike, 22, was admitted involuntarily to a locked ward and treated with antipsychotic medication. When he was discharged from hospital, he discussed this time with his therapist with a sense of confusion and awkwardness. The therapist realised that Mike could not fully recall the experience or explain why he was in a locked ward and given medication. Mike believed a precedent had thereby been set for how he would be treated in the future if he were to relapse and require hospitalisation. The therapist approached the situation by discussing with Mike the various aspects of psychiatric hospitals and the rationale behind some of the services.

Engaging and assessing an adolescent can be difficult work. There can be a range of issues involved, including developmental stage, intellectual ability, personality traits or phase of illness. These can contribute to the difficulty some young patients have in articulating a response to the type of questions asked during a COPE assessment. Fowler et al. (1995) adapted the Colombo technique into a strategy for information gathering that can be used throughout therapy. It involves having the therapist behave confused and apologetic in response to the patients limited responses, but having him or her continue to ask questions in order to gain details or clarification of the patients experiences. The therapist sets the scene so the patient believes the therapist is overwhelmed, or somewhat simple or concrete, and therefore needs the patients assistance to sort out the information that is being provided.

Case example The Colombo technique During an assessment, Samantha, 19, was evasive and unclear about her recent psychotic episode. She seemed vague and to be withholding some information. This is how the therapist responded to Samanthas state: From what youve been telling me, it seems like the last few months have been somewhat chaotic and uncertain for you. But Im finding it a bit hard to put all the pieces of your picture together. Could you help me out a bit?

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2.3 Determining the agenda for therapy

Before establishing the agenda for therapy, the therapist needs to feel satisfied that: a thorough assessment has been performed: a cognitively oriented assessment has been done in order to explore the impact of the psychotic episode the developmental and personal history has been completed the patient is engaged in therapy and is alert to the role of therapy: the patient is attending therapy appointments as required the rationale for therapy has been collaboratively explored and agreed on the patients mental state is stable; that is, there are minimal positive psychotic symptoms the therapist has developed an initial formulation, and the direction of therapy is clear: the therapist has an understanding of why the patient was ill at that specific time of life and with that specific presentation of symptoms the therapist has an understanding of the patients explanation of why he or she became unwell. In the therapy agenda, why the patient and therapist are meeting is explained. These issues should be re-stated to the patient: the role of the therapist; the length of therapy; the timing of the review sessions, and the recovery focus of the therapy. Determining the therapy agenda is an interactive process. Patients are asked about current problems and issues they would like to cover during the course of therapy. The therapist should also suggest agenda items that reflect the formulation and assessment. The agenda should reflect the focus of recovery in first-episode psychosis, but should also contain some flexibility in order to include specific problems experienced by the patient. Although therapy includes a structured framework, it must be tailored to individual needs and the therapists formulation. The agenda should include topics such as: What is psychosis? What happened and why? Have I recovered? Am I over it? How will I get over what has happened to me? How will I avoid it happening again? Relapse prevention and early warning signs. How to cope and deal with stress. What will my future hold for me now? Social environment and the presence of stigma.

The agenda includes a structure for therapy whereby the therapeutic process is demystified. Being clear with the patient is important, because psychosis is usually a very confusing and disempowering experience, and most people feel vulnerable in the postpsychotic phase. The agenda can be the framework for containing therapy; that is, the

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therapist will not introduce topics out of the blue for discussion. However, the therapist should be mindful that the post-psychotic phase is a variable state and that some flexibility is required because new topics might appear during the course of therapy.

Case example An agenda for therapy Jim, 24, experienced paranoid delusions and hallucinations for four months before being treated. His delusions were that people were watching him, stalking him and giving information about him to the government. His hallucinations were similar, whereby a male voice was telling him that people were watching him, and to beware. Jims friends and family were incorporated in his delusions, and he had lost contact with his peer group and left his job as a motor mechanic. Now in the recovery phase of his illness, Jim noticed he was having difficulty getting motivated to do anything, was lonely and was embarrassed about re-contacting his old friends. From information gathered in the assessment, it seemed that Jim had no rationale for why he became unwell and had a negative, toxic stereotype about mental illness; that is, he believed mental illness was a sign of weakness and that he was destined to be alone because of the stigma the community had about mental patients. Therefore, Jim held a belief about psychosis that was threatening to his self-concept and which could make him vulnerable to depression and poor recovery. When considering the agenda, Jim clearly wanted to work on his lack of motivation and wanted to occupy his time. When he was probed some more he reluctantly acknowledged that he missed his friends and wouldnt mind seeing them again, but that they probably werent interested in him anymore because of his illness. This led into a discussion of Jims views about psychosis, and to the therapist suggesting that Jim needed some factual information about his illness. The intention was to enable this topic to be included in the agenda so it would be possible to openly discuss psychosis and provide education about the experience. Therefore, Jims agenda for therapy was: amotivation work social network getting in touch with old friends Jims episode of psychosis the facts.

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3.

The therapeutic alliance

Assessment and engagement so that therapy can commence should begin as a parallel process. In this section, we elaborate on the engagement phase of therapy and the importance of developing a therapeutic alliance. We include some discussion of the difficulties involved in engaging older adolescents and young adults into treatment. The strength of the therapeutic alliance is a strong predictor of outcome, irrespective of the therapeutic approach. Weinberger (1995) and Mohr (1995) reviewed the importance of the therapists characteristics, and found that negative outcomes were associated with: lack of empathy underestimating the severity of the persons problems negative counter-transference poor techniques a high concentration of transference interpretations disagreement with the person about the therapy process.

For therapy to be beneficial, a secure base must be established between the therapist and the patient. As Perris (1989) states: The overall goal of cognitive psychotherapy is to help the patient to be conscious of his or her ruling convictions and self-opinions and to guide him or her to develop new and more functional meaning structures. We have found that desirable characteristics of a therapist working with young people include flexibility, collaboration, emotional attunement, and a strong knowledge of developmental and life-cycle issues. The therapeutic alliance and the assessment process will be augmented by understanding the context and influences within which a persons psychosis developed. The therapist is required to understand: the pervasive and individual effect of a psychotic episode on a persons life the variety of reactions a person can have to the experience of psychosis

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the persons sociocultural milieu the persons and carers initial attitudes to the services and treatments that are available.

3.1 Developing and maintaining the therapeutic alliance

A large body of literature exists in which the development of the therapeutic relationship is examined; however, yet little has been written recently about the therapeutic alliance between the therapist and a patient who has psychosis. Fowler et al. (1995) suggested that the process for establishing rapport is comparable to approaches in counselling psychology, whereby therapeutic skills such as listening, clarifying, summarising, and conveying empathy, warmth and concern are involved. Relevant issues in establishment of a therapeutic alliance, regardless of the patient population, include: conveying to patients that they are being listened to and taken seriously. The therapist should foster a relaxed and trusting atmosphere in which patients feel safe explaining the process of therapy, that is, the rules of the game. Patients might not be accustomed to the idea of therapy and therefore not know what to expect. For example, they should be informed about contact time, length of therapy, frequency and length of sessions, and the need to work collaboratively to establish an agenda for the therapy identifying the existing problems that patients are experiencing. The therapist should be an overt listener by prompting, then clarifying and summarising as patients tell their stories, yet allowing them space to ventilate their concerns.

It can be very difficult developing an alliance with a psychotic or post-psychotic person. It is useful to remember that the therapeutic alliance is a developing and dynamic process that may take time to evolve. Perris (1989) warned that the therapist must avoid being overcome by the patients negativity and passivity. The therapist must be aware of the patients relating capability and therefore pitch to that specific level. For example, a patient might respond to a behavioural approach rather than a cognitive approach, so the therapist would act to engage the patient using behavioural strategies. The therapist should continually assess the patients cognitive and emotional functioning and phase of illness, and pace the therapy accordingly. In this way, he or she should help prevent the patient from leaving therapy because of frustration or failure to comprehend the therapys content. Perris (1989) emphasised the need to be aware of non-verbal communications such as body movements, eye contact and physical stance, because it is through them that an understanding of inner experiences is gained. Noticing and commenting on behaviour or facial expressions can result in an opening up of discussion about the patients true feelings. The therapist should actively show empathy and warmth, both verbally and behaviourally. It is important not to be obviously shocked or judgmental about what patients say or how they behave; however feigning shock in a humorous way can sometimes aid communication. Humour can also be an excellent ice breaker, whereby the experience is humanised and the stereotypic perception of the therapist as authoritarian is challenged. Respect should be shown towards patients explanatory model of their psychotic illness and their subjective experience of it. The therapist should use patients own terms for describing what they have experienced, thereby enabling a common language to develop.

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Case example Being respectful of the persons terminology A patient who had experienced an episode of psychosis did not want to accept the term psychosis to describe what he had gone through. Instead, he acknowledged that he had been experiencing a rough time and needed assistance to get through it. The therapist recognised the patients perspective, discussed the illness in terms of a rough time, and initially concentrated on coping strategies. Therapist: Maybe we could go through the experience you had so we can learn something from it. What do you think caused you to experience such a rough time?

An avenue for discussion was thereby opened up through which many aspects of the illness could be covered, such as the precursors to it, explanations for becoming unwell and the illnesss effect on the persons self-esteem, whereby the therapist did not have to use the term psychosis.

The therapist should show patients that he or she is there to be of assistance. This idea can be expressed by identifying a problem or issue that the patient acknowledges and agrees to work on and including it in the therapy agenda. If the problem requires immediate attention, the therapist should discuss it immediately and thereby illustrate his or her flexibility and desire to assist.

Case example Dealing with the immediate problem Lizzy, 18, attended her fifth therapy session in tears, seeming distressed and very upset. She said that the previous day she had had a phone call from her ex-boyfriend, with whom she had experienced an abusive relationship. She felt frightened, and since the phone call, had been remembering specific details of the abuse she had incurred. The therapist approached the situation by concentrating on the immediate problem: Lizzy required reassurance that she was safe. The therapist debriefed her about her distress.

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The therapist should ask the patient whether he or she would like some practical assistance, for example with phone calls or transport. This question can be used to demonstrate how problem solving can occur.

Case example Practical assistance Sophie, a 22-year-old university student, had difficulties organising her study timetable. She felt unorganised, and kept changing her appointment time with her therapist from week to week. One response could be as follows: Therapist: It seems youre having some problems arranging your activities, and that youre finding it frustrating because you dont get some things done. I know Id be lost without my diary so maybe youd like some assistance with organising your timetable so you can get here on time as well as go to university and have some time for study and seeing friends.

The therapist should establish a convenient weekly session time and in doing so create a structure for the therapeutic process. However, he or she should provide for some flexibility in the structure, venue and length of therapy whereby the patient is able to have some control in the process. For example, sitting in an interview room might be an obstacle to facilitating easy dialogue for a patient who has poor concentration. The patient might become restless and uninterested, so it might be useful to change the venue or the length of the session. Some patients can feel more comfortable while taking a walk outside or sitting on a garden bench. The change might aid-development of an informal dialogue, and this less formal approach often works well for young people. If a patient cannot tolerate an individual session and leaves the therapy setting, the therapist should state that he or she would like him or her to return when ready. The therapist should then stay in the setting for the usual duration of a session, in anticipation of the patients return. In this way, the therapist demonstrates that he or she is persistent and that a defined time is available solely for the patient, whether or not he or she chose to use it. It is also important to follow up a patient who misses an appointment. The therapist should show respect for the patients time, be punctual for the session and alert the patient in advance when planning to take leave. To assist with potential crises during the leave and reinforce the safety of the theraputic environment, the therapist and patient could collaboratively decide on a plan of action if there is a crisis or a relapse of the illness. The plan would include early-warning symptoms of relapse, who to contact and how to contact him or her. The therapist should acknowledge the patients efforts and initiative. The acknowledgement can be as simple as praising him or her for attending the session on time or acknowledging that he or she has thought about the issues covered in the previous session. The patients strategies for coping in difficult times are thereby reinforced. Engagement is aided by maintaining an attitude of cautious optimism, instilling hope, and calmly accepting the content of psychotic delusions and hallucinations.

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Finally, the therapist should expect that some patients will resist engaging in therapy. They should recognise that an extended engagement phase might be necessary, respect the patients reasons and be persistent and patient.

3.2 Barriers to engagement

Developing a therapeutic alliance with a young patient who is recovering from his or her first psychotic episode is generally difficult. For a variety of reasons, the young patient might refuse to see the therapist, or might attend sessions but refuse to participate. It is important to keep a number of issues in mind when assessing how to engage a patient in therapy. Mental state The therapist must be competent in assessing mental state and phase of illness. For example, the patient might initially have some thought disorder and poor concentration. In this situation, the therapist should slow the process of assessment and/or keep the sessions short, to prevent the patient from feeling confused by the questions. The therapist should pace the therapy to mirror the patients mental state. The patient might be experiencing negative symptoms such as avolition or anhedonia. It might be appropriate to provide psychoeducation and reinforce the view that the person can influence the course of the disorder. This usually results in demystification of the experience by having it placed in context. The therapist should arrange appointments at a convenient time and when mental state is at its peak perhaps in the afternoon rather than early in the morning. Diagnostic issues The therapist should keep in mind the heterogeneity of patients who have early psychotic illnesses and the fact that it can be very difficult to make a definitive diagnosis at this stage. An initial or tentative diagnosis can be refined as time passes, and relapses can occur during therapy. Developmental issues Difficulties in engagement can be due to developmental issues and deficits in social or interpersonal skills. Most young patients have had no experience of therapy, have little or no idea of what is expected of them, and have little idea of what they can expect from therapy. They might not be used to meeting one to one and to talking about their feelings and concerns. They are not necessarily help seekers and might have been forced into treatment as a result of the severity of their disorder. Therapists should pitch their language to match that of their patients. They should continually assess the patients level of comprehension, which can change according to phase of illness, to ensure they receive appropriate information. Substance use Substance use before and after a psychotic episode is common among the members of younger age groups, and patients can attend sessions under the influence of drugs. It is useful to make an agreement with them not to take drugs before attending sessions, in order to ensure alertness and ability to participate. It is important to assess the rationale behind drug-taking behaviour. Patients might say they take the drugs to reduce the severity of their problems, which can include social

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avoidance, stigma or residual positive symptoms. The therapist should immediately attempt to target these issues, and focus on adaptive problem-solving techniques and behaviours. Personality issues Pathological behaviour due to personality disorders or traits can be an obstacle to engagement. The therapist should be able to recognise the signs and respond accordingly. It is difficult to build rapport with someone who is suspicious and distrusting, as occurs in paranoid personality disorder. The therapist should demonstrate genuine openness in an attempt to build trust. COPE is not a therapy for treating personality disorders; however, the therapist should bear in mind that the process will be influenced by the patients personality style and the presence of any personality disorder. A thorough personality assessment is required in order to assess the impact of these factors.

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4. Adaptation

Psychosis is often, but not always, experienced as a personal disaster and a highly damaging mix of secondary trauma and loss. A successful coping response to a psychotic episode will reflect the range of adaptive responses that are used in other crises and disaster situations. Preventive intervention aimed at promoting adaptation and focusing on the impact on the self is consistent with the brief psychotherapy crisis intervention paradigm. The aims of this approach are to: assist the person in undertaking a search for meaning in the experience promote a feeling of mastery over the potentially disempowering experience protect and improve self-esteem, which might have been severely threatened or damaged as a result of the onset of the disorder.

The unifying theme is the capacity to form and maintain a set of illusions; in other words, recovery from potential disaster depends on being able to look at the facts in a specific light. How the person appraises his or her psychotic illness (it might be positive, or he or she might wish to defend against it by denying it) can influence the recovery process. This cognitive process of appraisal, which is fundamental to the concept of coping, is amenable to intervention. Successful intervention will aid the person in making a positive adaptation to the onset of the disorder, play an active part in managing it, and aid the person in maintaining the best possible quality of life. The strategies used in COPE aid the person in challenging his or her appraisal of the psychosis and of himself or herself, and include evaluation of self-worth; also, they act as a bolster for adaptive coping responses and resources. A fundamental issue is patients explanatory model and level of insight. This issue includes the extent to which patients are aware of a significant change in their experience and behaviour, and the extent to which they acknowledge this awareness (Amador et al. 1991). If patients acknowledge a change in mental state, the therapist should use the opportunity to explore the explanatory model for this change as a basis for developing a framework for adapting to the disorder. COPE is distinguished from other

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cognitively based therapies by virtue of its focus on the patients underlying idenity. In particular, as the young person begins to emerge from the acute phase, the therapist aims to develop an understanding of the impact the psychotic episode has on individuals views of themselves. The task of appraising and adapting to the onset of a psychotic disorder is influenced by a range of personal characteristics, including: the pre-existing level and quality of coping skills and resources, such as family social support, problem-solving abilities and attribution style the persons personality structure the underlying structure and stability of the self-concept, and the complexity and coherence of the self-concept core beliefs and schemas.

Factors that affect the persons appraisal of the psychotic experience include issues that are external to the self such as: age at onset of psychosis rate of onset of the initial episode co-morbidity family psychiatric history.

Before commencing identity work, the therapist should assess the stability and diversity of the patients identity. This assessment would include examining the perception of pre-morbid personality and current sense of self. Apart from interviews, school reports are a good source of information. This assessment is important for understanding the impact of psychosis on identity; that is, has the previous sense of identity been replaced by an illness model, and what are the implications? It is also important to understand the patients: current and previous mental state (positive symptoms, negative symptoms, mood and co-morbidity) degree of trauma and loss experienced during or subsequent to the psychosis level of awareness of change and insight into change rate of onset of the psychotic episode (protracted or rapid onset) response to onset of psychosis and treatment (which can be integrated, whereby the person acknowledges experiencing the disorder and wants to understand psychosis, or can be sealed over, whereby there is a sense of denying being psychotic or refusing to accept information about psychosis) sense of self or identity (past self, current self and future self) explanatory model (illness stereotypes) coping repertoire level of knowledge of psychosis quality of the recovery environment level of illusion (how is the patient viewing the facts?) level of self-esteem.

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4.1 Psychoeducation
Psychoeducation is an important strategy for reducing the distress and disability associated with psychosis. Having accurate, tailored information can be the basic framework for understanding puzzling experiences. It is important to be mindful that the person is attempting to compensate for not only the cognitive and emotional disruptions wrought as a result of the trauma of the psychotic symptoms but the assault on self-esteem and identity and the disruption to lifestyle. The person is grappling with the meaning and significance of his or her predicament while still in a highly compromised state. In much of the information to be communicated, the focus will have to be on individual symptoms and problems; however, some general issues also have to be considered. These include diagnosis, the phases of illness, examining illness models, and exploring the impact of psychosis on the sense of self or identity. Diagnosis Lack of diagnostic clarity and stability is common in early psychosis, but at the same time, major diagnostic concepts such as schizophrenia can have stereotyped and unhelpful connotations for prognosis. Two techniques can be useful in communicating an accurate diagnosis and de-toxifying the experience. The first technique is to accept the existing Axis I classification system but re-form the stereotypes in line with more-accurate recent evidence about the course of the various psychotic disorders. For example, it might be helpful to review together the patients file notes, and in reviewing them, to explain the language and answer any questions. In doing so the experience can be demystified and the patient can learn about the mentalhealth system. The patient can be engaged in the educational strategy of drawing diagnostic circles, whereby the therapist draws a large circle labelled Psychosis and a series of smaller circles that overlap with it and are labelled according to the various psychotic diagnoses. The therapist describes in detail the areas that are common to each diagnosis. Psychotic symptoms are explained under the headings, for example confused thinking, false beliefs, hallucinations, changed feelings and changed behaviour. It is important to discuss the similarities and differences between each of the diagnostic labels in terms of the illnesss cause, the vulnerability factors involved and the course of the illness. This technique is useful for discovering whether patients view themselves as having a diagnostic label, which label they have, and why they have it. It is also used to explain the terminology, to correct irrational assumptions about mental illness (particularly the term schizophrenia) and to de-catastrophise the experience of being diagnosed by placing it in perspective. The second technique can be used with someone who might find diagnostic labelling confusing and need a simple structure in order to understand psychosis. In this approach, the diagnostic message is kept simple, general and clear. For example, it can involve communicating that the person has been going through an experience that is serious yet is one from which he or she will substantially recover. Therapists need to demonstrate that they recognise the pattern of symptoms and can give them a name. For example, the concepts of confused thinking, poor concentration or paranoia can be useful to name in order to discuss the experience. The general phrase acute psychotic episode can be used to convey the meaning of the experience, and the therapist can point out that the concept is similar to other syndromal diagnoses in medicine such

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as acute asthma attack. Possible sub-categories of psychosis can be discussed, but not emphasised unduly or presented as disease entities. Phase of illness In an interactional-psychoeducation model, it is implied that information is carefully tailored to the individual. Information about the patients own symptoms is most useful and likely to be remembered better than more-general material about psychopathology and diagnosis. Maintaining a specific focus on the most relevant issues for each person is likely to be more effective and less likely to stimulate resistance and denial. The style of working with the patient has to be linked to how the individual learns and absorbs information. The content of the material also has to be carefully tailored for the individual according to his or her phase of illness.

For example Psychoeducation: phase of illness Melanie, 18, had experienced psychosis for the past two years, following a one-year period of prodromal symptoms. This three-year history of illness has resulted in significant interference in her education and social relationships. In the early stages of Melanies recovery, information about psychosis was delivered in such a way that her current anxieties were relieved. She was reassured by the therapist, current events were explained to her, and she was taught coping strategies in order to enable her to deal with the situation. Later, in the recovery phase, the therapist discussed psychosis in terms of Melanies actual experience. The causes of her symptoms were discussed in terms of her response to stress in conjunction with marijuana smoking. The descriptions of her symptoms were used to highlight and understand a therapy-agenda item entitled What is psychosis?. The length and course of Melanies illness were used as the basis for discussing diagnostic issues and possible early-warning signs of relapse, whereby discussion was prompted about Melanies vulnerability to relapse. During the acute phase, Melanie experienced difficulties with processing information. The therapist used video material as a phase-appropriate vehicle for commencing therapeutic work on psychoeducation issues, along with structured, concrete discussions. Later in Melanies recovery, she was comfortable with engaging in reading tasks and less concrete discussions.

Illness model There is a need to explore, understand, accept and monitor each individuals understanding of the nature and cause of the illness. It is important to identify the fears and expectations about psychosis at the earliest possible stage, because the personal explanatory model can be influenced as a result. At the same time, it is important to present alternative explanations and coping strategies. The therapist thereby enables an alternative model to be considered rather than an unchallenged and possibly stigmatising illness model to become entrenched. The

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rate of assimilation of an alternative model will vary considerably and is influenced by factors that include protective denial. When resistance, denial or a particularly unhelpful lay model are a serious threat to the persons well-being, a more active intervention might be required. For example, the therapist might inform the person about some real-life case examples of people who had a psychotic illness but then had a positive outcome. In general, however, denial should be respected during the early stages of recovery and should be challenged carefully. Patients can be most reluctant to talk about their experience of psychosis. They might actually believe they were not psychotic, just misunderstood. If this style of explanatory model is preserving the patients self-esteem and the patient is not at risk of psychotic relapse, it would be unwise for the therapist to disrupt this point of view during this phase of therapy. Some patients who use this explanatory model are able to consent to medication and comply with appointments. It is important to engage with the persons healthy component and to continue with this illusion until the resistance about the psychosis dissolves. The person might wish to work on other issues such as anxiety management, assistance with social or work issues, or levels of confidence.

For example Illness model Maria, 25, said her major problem was the distress she had experienced as a result of feeling awkward around her peer group since being discharged from hospital. She wanted to wipe the slate clean and start afresh. She did not want to consider what had led to her being hospitalised, and did not want to concentrate on the negative influences of her past. The therapist was left with a specific path to follow. Marias dismissive denial style was typical of the sealing over recovery style. To keep Maria engaged, the therapist addressed her immediate concerns. The therapist started to explore Marias thoughts about why she felt awkward around her friends. Maria expressed concerns about her reduced confidence and self-esteem since her hospitalisation. Her greatest fear was that people would think she was now tainted because she had been admitted to a psychiatric hospital. It seemed she felt stigmatised. The initial task was to help Maria feel comfortable with her friends. This outcome was achieved through looking at her thinking and considering other rational hypotheses, whereby she was assisted to become more involved socially with her peer group. Graded tasks were useful, such as those encapsulated in the following dialogue. Maria: Therapist: I dont enjoy being around people that much any more. Do you feel like this around everybody, or around just some people? Its really only when Im around some of my friends. How do you feel when youre with these people? I feel edgy and uncomfortable.

Maria: Therapist: Maria:

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Therapist: Maria:

Can you tell me more about those feelings? Im not sure I can ... its just a bit overwhelming, seeing everyone again. What do you think about when you see everyone again? I think they think Im a loser. What do your friends do or say that gives you that message, that youre a loser? Well, its hard to say, but some people look awkward around me. Could you explain that to me? Well, Mike just says a few things to me and doesnt talk much. Does he do this with just you or with everyone? Mike is like this with most people, I think. So, if Mike is like this with most people, does it seem likely that he is going to be like this with you as well? I suppose so. I wonder if youve been interpreting events when youre with your friends in a negative way, when in fact your friends are treating you just the same as usual. Maybe. Maybe we need to explore this some more. Itd be useful for you to try to identify your thoughts when youre around your friends; then we can look closely at your thoughts to see how youre interpreting events that happen around you. OK.

Therapist: Maria: Therapist:

Maria: Therapist: Maria: Therapist: Maria: Therapist:

Maria: Therapist:

Maria: Therapist:

Maria:

Through looking at dysfunctional thoughts and behaviour strategies, Maria was able to feel more confident around her friends. The next task, once Maria was happy with how things were with her friends, was to slowly explore the issue of stigma and enable Maria to develop a less negative catastrophic view of her episode of psychosis. This second step can be difficult, but once a patient has experienced a success, he or she is more engaged in therapy and more likely to trust the therapist.

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Meaning, mastery and self-esteem Psychoeducation can affect the adaptational variables of meaning, mastery and self-esteem, which are critical in overcoming threatening life events. Providing and shaping a sense of meaning for inexplicable experiences can be very helpful in sustaining a sense of self and continuity for the person. Mastery is promoted through acquiring knowledge, particularly if the process involves learning about help seeking, self-monitoring, relapse prevention and active coping strategies. Through adopting these approaches, fears of relapse and of the accompanying loss of control can be assuaged. The stigma attached to the persons own stereotypes of mental illness is a threat to self-esteem that leads to activation of protective cognitive biases. This outcome can be circumvented by softening or detoxifying the stereotype through providing more-appropriate content, such as reading first-person accounts of psychosis and providing information in a specific and problem-focused way.

The content of the psychosis is potentially useful to know in understanding patients, but patients explanation of their experiences should be respected. Conveying the impression that the symptoms are completely bizarre or unintelligible can be destructive. In early psychosis, pre-existing psychological conflicts and unresolved issues can often be recognised within the psychotic experience. It is usually not appropriate to provide the patient with direct interpretations during an early phase of illness, but it is useful to show active interest and confirm that the experiences are worth trying to understand. The therapist should seek to discover the rich tapestry of the psychotic experience, if it is forthcoming from the patient. Some useful prompts include: What were the experiences? When did they commence? What did they mean? Whose voice did you hear? Where were you when it happened? What does death, religion, hearing voices, being the chosen one and so on actually mean? How did you respond? Why respond in that way? What follows now?

Materials and handouts It is important to have access to a range of materials, in a variety of styles, that can be tailored to the individual experience and interests. Materials can include: audio video materials such as the EPPIC community video A Stitch in Time: Psychosis Get Help Early, in which the acute and recovery phases of psychosis, are defined and are illustrated by first-person accounts. Showing the video is a useful way to access peoples explanatory models and mental-illness stereotypes and normalise the experience. reading material from the book series Overcoming Common Problems, published by Sheldon Press, London

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the video Holding On To What Is Real the video One in Five, from the Victorian Department of Human Services the computer program Alice Files the Early Warning Signs, questionnaire (Birchwood, 1996) the EPPIC Psychoeducation Manual (1996)

Psychoeducation, when viewed as being a psychotherapeutic tool, can be effective only in the context of a strong and sustainable therapeutic alliance. Psychoeducation is a process that takes time.

4.2 Vulnerabilitystress model

Apart from providing a diagnosis or name for a psychotic disorder, it is usually helpful to present a model of the disorders underlying nature and how the disorder came about. The vulnerabilitystress model (Zubin & Spring, 1977) has become the dominant conceptual framework for understanding psychosis. It is a simple, practical framework through which the patient is able to have an active role. A range of problem-oriented intervention strategies, outlined as follows, can be used to decrease stress or vulnerability and increase the threshold for psychosis. Although the model has evolved into several versions, Zubin and Spring originally proposed that each episode of psychosis is triggered by a challenging event that exceeds the individuals vulnerability threshold. They said that vulnerability could be acquired or transmitted genetically, and was offset by the individuals coping capacities and ability for adapting after each psychotic episode. Their view was a challenge to the assumption that psychosis was a disease characterised by inevitable deterioration, and as a result, an impetus was provided for maximising adaptive functioning and relapse prevention during the recovery phase. The model is similar to that of physiological vulnerability in conditions such as asthma, in which there is an episodic course and a potential for resolution of the vulnerability. In some cases, though, there is entrenchment of respiratory impairment and disability. Vulnerability is an excellent organising construct for problem-oriented psycho-education. The patient can be invited to actively participate in the process of reducing vulnerability and raising the threshold for relapse through the following strategies. Stress management. Understand the relationship between stress and the onset of prodromal or psychotic symptoms, and learn new ways to respond to stress in order to reduce the possibility of relapse. Adherence to medication regimens. Educate the patient about medication and its use over the course of the illness. Discussing it in terms of acting as a safety net can be useful. Avoidance of illicit drugs. Discuss the role of drugs in relation to the onset of psychotic symptoms. Recognition of early-warning signs. Review the course of the illness from the prodromal phase through the acute psychotic phase to the recovery phase; then examine the prodromal symptoms that were noticed first. Preferably do this in conjunction with family and friends. Harnessing of social support. Examine patients social support networks, and find out who they can contact if they are feeling vulnerable to relapse.

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Exploration of effective help-seeking strategies. Explore what coping strategies have been useful for decreasing vulnerability. These can be learning to relax when stressed, deliberately having quiet nights during periods of sleeplessness, or contacting the doctor. Development and/or maintenance of rewarding social and/or vocational roles. Find rewarding social and vocational roles to aid self-esteem and act as social support in moments of vulnerability. Creation of a plan for relapse prevention and management. Learn about earlywarning signs of psychosis, and develop a strategy for dealing with them. The plan might initially involve reducing anxiety and using supports, then contacting the doctor. Re-examination of the plan. Having information carefully tailored to the individual can be empowering, and can act as an antidote to the possibly demoralising influences otherwise at work in the patients situation. For example Vulnerabilitystress model Lucy, 27, experienced a psychotic episode with an insidious onset over two years. Her symptoms included systematised paranoid delusions that her family and neighbours were watching and videotaping her. During this time, she was unable to properly care for her four-year-old son because she was increasingly distracted by her auditory hallucinations, in which she was being told she was being watched because she was worthless as a mother. During her recovery, Lucy described a chaotic childhood. Her mother was ill for most of the time, with untreated schizophrenia. As a result of her mothers delusions, her father was forced from the family, because the mother believed he was the devil. As a result of the situation, Lucy was forced to abandon school and commence mothering her younger siblings and mother. When Lucy recovered, she had developed insight into her illness but feared it might take a similar course to that of her mothers. She noticed that whenever she became anxious about something, it would eventually escalate into fears that her son would be taken away, and the voices were then likely to return. A personalised stressvulnerability model was generated to assist Lucy in understanding her symptoms. Her genetic vulnerability to psychosis and memories of her mothers illness were discussed. Lucys general fear of losing her son and, like her mother, of being helpless, were thereby revealed. It was important to highlight the differences between her mothers illness and Lucys illness, using psychoeducational methods such as the diagnostic-circle technique. Lucy learnt about schizophrenia, and realised that the development and symptoms of her illness were different from her mother. It was emphasised that Lucys auditory hallucinations appeared only when she was anxious. Lucy was able to understand the reasons for her vulnerability to relapse, based on her genetic make-up and her anxieties about the consequences of mental illness. She also realised her ability to influence the course of events that led to relapse. She discovered that when she did become anxious, she could contact one

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of her sisters or a girlfriend and talk to her. The escalation of anxiety was thereby effectively prevented, and auditory hallucinations were also prevented. Through recognising this pattern, Lucy was able to take control of the situation, from the early onset of environmental stressors, and to change her response to them and reduce the risk of relapse.

Timeline Another useful technique for demonstrating the link between stressvulnerability and psychosis is to ask the patient to draw a timeline (with the help of the therapist, family member or friend if needed) that includes the onset of prodromal, affective or psychotic symptoms in relation to life events. Through using this technique, the patients early warning signs of psychosis can be elicited and the role of stress in the development of psychotic symptoms can be highlighted (see Birchwood, 1996).

For example Timeline Dominic, a 24-year-old outpatient, was asked about the course of his psychotic symptoms in terms of what else was occurring in his life. Dominic said he was unsure, but that the lack of surety led him to feel vulnerable to becoming psychotic again at the drop of a hat because he could not identify specific early-warning symptoms of psychosis or stressors that might have triggered his psychosis. Figure 1 The timeline which Dominic worked out with his therapist
Prodromal symptoms Psychotic symptoms

Feeling happy and excited Starting to feel stressed and anxious Becoming forgetful, not sleeping well and feeling low in mood

Being paranoid staying indoors. Being fearful ...

Commencing relationship

Living with girlfriend Using cannabis

Losing job

Date of hospital discharge Date of hospital admission Current date

Having car accident and arguing with parents

The therapist used the timeline technique in order to explore this lack of surety, by placing anchor points such as the current date and the dates of hospital admission and discharge. Collaboratively, Dominic and the therapist filled in the gaps. First, the therapist asked him to recall what he had been doing over the

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past 12 to 18 months. A backdrop was thereby set, against which the prodromal and psychotic symptoms developed. Dominic started to recall events in his life before he had become unwell, including his smoking of cannabis, commencement of a new relationship and its sudden development into living together, loss of his job, arguments with his parents and involvement in a car accident. The therapist then asked Dominic to recall when he had noticed he was not feeling his usual self the commencement of prodromal symptoms that developed into psychosis. The opportunity was thereby provided to discuss an explanatory model for why Dominic became unwell, and the role of stress and confusion in the aetiology of his symptoms. It can be useful to use other sources of information to fill in the timeline, by referring to documents such as the discharge summary in the medical file or asking Dominic to check with his family and friends about the timing of significant events.

The vulnerabilitystress approach can be a challenge to people who use a catastrophic view of psychosis, that is, who believe that psychosis came from nowhere and will come again without any warning. It can be used to help dissolve any sense of ineffectiveness by challenging the distortions about psychosis. In the model, vulnerability can also be presented as undergoing an evolution, with the possibility of reducing it over time through processes such as maturation or compensation. Vulnerability is a very general normalising concept that can be applied in many health-care settings across a range of disorders. People are thereby helped to view their illness and its course in a less stigmatised way, and similar to physical problems such as asthma or diabetes. Through talking about vulnerability, the therapist can avoid giving the impression that the patient has a fixed, permanent illness and will need to take medication forever. In early psychosis, it is important to focus on the immediate future. Most patients will agree that medication is necessary for a period of a few months while they get back on track, because they feel vulnerable in the wake of a first psychotic episode. For patients who seem to require continuing medication, a second stage of psychoeducation based on phase of illness is necessary. For these patients, it is more acceptable to use concepts such as recovery and vulnerability and to recognise the possibility for change rather than to deliver pronouncements about the long-term course and treatment.

4.3 Identity work

Repertory-grid technique The repertory-grid technique is a useful tool for exploring patients sense of self and the impact of personal stereotypes about mental illness on their view of themselves. The technique is a modified version of the technique first described by Kelly (1955). The notion of possible selves represents the range of hopes, fears and fantasies that people have about the future.

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For example Repertory-grid technique Before becoming psychotic, Bill, 17, had a clear and positive view of himself in the future. He intended to complete school and then work in his familys courier business full time. After the psychotic episode, Bill had a different and pessimistic view: he saw himself as being dependent on, and a burden to, his family. His past view of himself was lost and replaced with a repugnant sense of self. The grid technique was used to draw out this information about his views of himself. Figure 2 Bills Grid How do I see myself now? Dependable Healthy Independent Trustworthy Reliable Motivated Happy 1 1 1 1 1 1 1 2 2 2 2 2 2 2 3 3 3 3 3 3 3 4 4 4 4 4 4 4 5 5 5 5 5 5 5 6 6 6 6 6 6 6 7 7 7 7 7 7 7 Not dependable Sick Dependent Untrustworthy Unreliable Unmotivated Sad

Other grid elements or headings How do I see myself in the future? How do I view someone who has schizophrenia? How do I view someone who has bipolar disorder?

Using the grid technique, the impact of a change in life circumstances is able to be assessed, monitored and kept in focus during therapy. The therapist asks the patient to do some or all of the grid elements at different times throughout therapy, and directs discussion in order to disclose the patients view. Irrational assumptions should be challenged using the CBT approach. The technique is useful for accessing patients core beliefs about themselves. It also acts as a reference between phases of illness so that the patient can see the recovery process in action and note improvements over time. Timeline technique The timeline technique, as described in this section in relation to the stressvulnerability model, is also useful in exploring identity issues. The therapist can catalogue the healthy characteristics of the person and differentiate aspects that are illness specific from those that are not. The technique involves providing a timeline and having the person describe how he or she sees himself or herself: before becoming psychotic when acutely psychotic now in the future.

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Figure 3 Timeline: Perception of self

Before psychosis During psychosis Current self Future self

Open minded Generous Outgoing

Frightened Evil Paranoid

Introverted Reserved

Knowledgeable about self Outgoing

The person will probably define positive and negative attributes at each of the four time points. This allows the person to distinguish between trait and state, and to separate the person from the illness called psychosis. Engulfment is thereby prevented and patients are given the opportunity to think about who they are and how they respond to life circumstances. If patients are reluctant to respond to this exercise, the therapist could suggest they ask family and friends what they thought about them at each of the four time points. If patients are shy or unable to participate, the therapist could engage in this activity, by saying, for example: Currently I see you as a punctual person who smiles often. Have you always been like this? Action COPE For less introspective patients who are recovering from psychosis but have lost confidence, are demoralised or are cognitively challenged, a more behavioural approach to promoting adaptation and recovery might be appropriate. The goal is for patients to witness their successes, whereby the way they view themselves and their world is in turn changed. Patients might believe they are unable to relate to other people comfortably because of their behaviour before treatment or because of fear about other peoples reactions (stigma). If it is not possible to successfully challenge these assumptions cognitively or in verbal sessions, a more active approach known as Action COPE can be effective. This involves challenging the assumptions and fears in a graded way by setting up reallife experiences, for example travelling on public transport or meeting friends again for the first time after hospitalisation. This can be achieved with the aid of the therapist, who can concurrently help to lay down new and positive cognitive schemas.

For example Action COPE In the previous example, Bill had acquired the belief that he was useless and unable to continue at school or work part time in the family business. He believed that psychosis had destroyed his life and he was useless. Bill did not respond to discussions because he did not believe in the non-toxic stereotypes of mental illness he believed mental illness was a life sentence of instability, dependence and rejection. The therapist decided that Bill needed to experience acceptance and some autonomy again. Bill hesitantly agreed to accompany the therapist into the city, and

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was encouraged to take control of the outing. This decision involved buying the tickets for the train trip and selecting the activity the two would do together. Bill chose to go to an electronic-game centre, at which he enjoyed playing the games something he had not done since the onset of psychosis. As a result of the experience, a discussion was prompted about state versus trait (as described in this section). The psychotic illness had not resulted in removal of his enjoyment of electronic-games, so what else about Bill had the episode not affected?

Re-framing Language through which aspects of the illness are re-framed in a positive light can aid protection of self-esteem (Strauss et al., 1985; Kingdon & Turkington, 1991). Periods of stable functioning, which can be characterised by social withdrawal and little outward improvement, can be described in a neutral or positive way as periods of practising old skills (for example when someone goes back to work after a long holiday), rather than with pejorative terms such as residual or deficit states. In this more positive approach, it is suggested that the person has chosen a specific course for a reason and is in control of life, and that a positive outcome is possible or even likely. This stance can be taken with a range of psychopathological and course-related elements of illness. Its aim is to normalise the experiences, to neutralise the stereotypic threat and ultimately to protect self-esteem.

Case example Re-framing Kate had been free of positive psychotic symptoms for eight months following her first psychotic episode, but was socially withdrawn, less active and feeling flat compared with before the illness. The therapist positively re-framed Kates current status, by emphasising that her current feelings were state based not trait based, that is, part of the recovery stage rather than part of her personality. The therapist asked Kate to list characteristics through which her personality could be defined, then explored the current existence of these traits. The therapist asked Kate to seek her familys and friends descriptions of her. Kate returned to the next therapy session with a list of personality features that included caring, sensitive, intelligent, friendly, humorous and quick tempered. These were then separated from her illness; that is, her personality was the same, but she was undergoing convalescence and needed time to develop strengths in order to move on again. The therapist can assist in this task by developing strengths and coping strategies through cognitivebehavioural approaches such as role-plays, the four-column technique (see the following section) and psychoeducation about the recovery phase and negative symptoms.

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4.4 Coping enhancement

Therapy can aid strengthening of general coping resources, specifically in relation to the challenge of the psychotic experience and diagnosis. Coping strategies are particularly useful in the early to middle phases of therapy, because patients tend to respond initially to a slightly more behavioural approach. This technique is based on developing a shared understanding of patients repertoire of coping mechanisms, followed by a focus on how they have coped with psychosis and its aftermath. The therapist should reinforce strengths by recognising that the person has been through a rough time and done well to date, and at the same time suggest there might be even better ways of coping. The therapist could draw attention to the under-use of strengths, for example by taking stock of personal assets such as: social, vocational and environmental supports interpersonal and communication skills personality style insight.

New coping strategies can be developed through learning from other peoples experiences. This can be achieved through referring to published information such as guidance books, psychoeducational material and first-person accounts. The therapist can also encourage the patient to establish contact with peers, self-help groups, mentors or psycho-educational groups. The vulnerabilitystress model of psychosis is especially useful when addressing issues of coping, because it includes an active role for patients in managing their disorder. Social-circle technique It is useful to spend time examining the quality and quantity of the patients family and social networks. This quickly provides an impression about ho is important to the patient, who knows about the illness and who the patient believes can be a reliable monitor of his or her mental health. It is often a relief for patients to know they can rely on someone in their social circle. This information is also useful when developing with the patient a plan of action for possible relapses. Information can be gathered about potential supports using the social circle technique. The patients name is written in a circle, and other circles are drawn around it, including the names of family and friends. These names are placed closer or further away from the patients name, depending on the quality of the relationship. Using this technique is also a good way to explore and discuss stigma issues. For example, the therapist might ask, Who in the social circle knows that you experienced a psychotic episode? followed by, Why do some know and the others dont know? Why do you not want them to know? This can result in discussion about stigma and enable the therapist to detoxify harmful stereotypes. It can also result in highlighting of who could assist in monitoring the patients mental health and aid identification of early-warning signs of relapse.

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Cognitive coping strategies By the middle phase of therapy, there should be a shift in coping strategies from the behavioural to the cognitive. Once the patient has a repertoire of behavioural coping strategies, the next task is to look at the cognitive element of coping by challenging distorted thinking patterns through which uncertainty and anxiety are produced. Some techniques for this are covered in the following sections, and in cognitive-behavioural textbooks, including Beck et al. (1979). Some points to consider are as follows. Challenging stereotypes of psychosis. Explore the persons stereotypes of mental illness and inquire into the cause of his or her thoughts and previous experience of mental illness. Socratic questioning is useful. Challenging the persons views about events and his or her involvement in them. Some patients misinterpret events and judge themselves harshly in these circumstances. It is important to tease out what the patient is thinking and then challenge the thoughts that are distorted. The four-column technique (Beck et al., 1979) is useful. The empty-chair and role-play techniques are useful when patients have difficulty coping in a specific situation because they become anxious. For example, a person might be unable to speak to a specific individual or have trouble visiting someones home. Using the empty-chair technique, patients can confront their fears by rehearsing what they would like to say. Role-play in a therapy session can also be helpful.

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5. Secondary morbidity

The aim of focusing on secondary morbidity is to improve and/or maintain quality of life by minimising the negative impacts of psychosis such as stigma and social withdrawal, and maximising protective factors such as self-esteem. Success in adapting to the experience of psychosis should result in reduction of secondary morbidity. It is not uncommon for patients recovering from an initial psychotic episode to develop additional disorders such as social phobia, depressive disorder, post-traumatic stress disorder (PTSD), and alcohol or drug abuse. The symptoms might not be sufficiently severe to meet the criteria for a formal diagnosis; nevertheless, they will impede the process of recovery. In COPE it is recognised that sub-threshold variants of disorders such as depression are worthy of assessment, treatment and prevention. Disentangling pre-morbid disorders from co-morbidity or secondary morbidity can be a challenge to even the most experienced clinician. The central issue in assessment and treatment is that secondary morbidity must be viewed in relation to the primary psychosis; that is, the secondary condition (for example depression) would not have arisen if the patient had been able to adapt to the primary condition (psychosis). For example, post-traumatic stress disorder might have arisen in response to events surrounding admission and treatment of the psychosis. Flashbacks, nightmares and intrusive memories might revolve around police involvement in an admission or being forced to stay in hospital or restrained by hospital staff. In addition, the patient might have found the experience of psychosis itself to be traumatic. Substance abuse is another example of secondary morbidity. Drugs and alcohol might be used with the intention of erasing or alleviating primary psychotic symptoms and secondary conditions such as anxiety. The overall effect is a numbing or blocking out of the experience, which can impede recovery.

5.1 Assessment
It is important to explore the parameters of the specific disorder when assessing secondary morbidity. This assessment should include the range, severity and intensity of symptoms. For example, if a patient has social phobia, the therapist needs to examine

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specific situations and to determine the conditions that exacerbate symptoms. These might include the presence of strangers, authority figures or large groups of people. Assessment of secondary morbidity also involves identification of the patients schemas (thought processes). For example, depressive schemas can include the following. My life has been irreversibly changed. I have no future now. Im unlovable. Ive lost my job; Ill never work again. Ill never be able to study again.

Anxiety schemas might include concerns about stigmatisation such as the following. Will my friends/family/colleagues still accept me? Theyre thinking Im mental. Theyre thinking Im dangerous. They think Im no good at my job now Ive been in a psychiatric hospital. I cant see my friends any more.

It is important to clarify what the patient can realistically achieve in the medium-term future, or over the length of therapy. The role of the therapist is to assess the patients strengths and weaknesses before embarking on the secondary-morbidity focus. The assessment would cover the following. Which syndromes are present, for example: depression anxiety PTSD social phobia substance abuse personality disorder or traits Degree of severity Pre-morbid factors that may be related to current secondary-morbidity Self-esteem Coping repertoire how effective, ineffective, adaptive or maladaptive? Help-seeking skills, attitudes and social supports Level of stigma Level of insight Quality of life and role functioning Social network

5.2 Strategies and techniques

Strategies and techniques in which the focus is on secondary morbidity include training in social skills and problem solving whereby dysfunctional thoughts and behaviour can be altered. The aim is to help the patient become less vulnerable to external stressors and be more aware of potential inner resources whereby greater independence and

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satisfaction with life are facilitated. Perris (1989) acknowledged that therapeutic techniques are merely aids with which to maintain a structure and facilitate the therapeutic process. Distancing and psychoeducation Many patients experience negative symptoms during the recovery phase of the psychotic disorder, so it can be difficult to be motivated enough to attend therapy sessions. Patients might interpret their ambivalence as absolutist and moralising (Perris, 1989), and say, for example, I am lazy, and Ill now always be lazy. If this thinking is not addressed quickly it can cause significant problems for therapy. It is useful to explain what might be going on in terms of the phases of recovery, through psychoeducation and an explanation for the presence of negative symptoms. This process is termed distancing, whereby patients are helped to dissociate themselves from their disorder. It can be reassuring for patients who complain about experiencing amotivation and asociality ever since the psychotic episode. Psychoeducation is a valuable tool for providing a clear message that a period of convalescence is necessary in the aftermath of the illness (Strauss et al. 1987). This message can be delivered simply and succinctly. For example, if a patient is worried that hypersomnia is interfering with energy levels for everyday activities, the therapist might respond by saying, Its okay to sleep for longer than usual, because you need the rest. You have experienced a shake-up in your life, and your body and mind need to recuperate so you can get back on track with your life. Trauma and debriefing The trauma of becoming psychotic, being admitted to a psychiatric hospital, being restrained and being medicated can have lasting implications for recovery. It is possible to under-estimate the significance of the psychotic episode or the circumstances surrounding it. Patients who experience PTSD related to their psychosis can have anxiety attacks when reminded of the trauma by way of sounds, smells, places or people. The patient can experience confusion about these otherwise unrelated prompts that unleash such strong reactions, and PTSD might lead to prevention of social or occupational integration. Working with PTSD can take longer than a specified 40-minute session. It is important for the patient to describe the symptoms such as anxiety, flashbacks, sleep disturbances or emotional numbness. The therapist should provide a safe place for patients to describe their fears, whereby a strong therapeutic alliance is required. The therapist should then attempt to debrief the patient by allowing them to experience the same emotional intensity when recalling the trauma within the therapy session. McCann and Pearlman (1990) provide more information about the treatment of post-traumatic stress disorder. Through the experience of psychosis, an anxiety response to a previous traumatic experience, unrelated to the psychotic episode, can also be unearthed.

Case example Previous trauma unmasked Sam, 28, received COPE after experiencing a psychotic episode. The episode was acute in onset, and the symptoms were delusions of reference as well as grandiose and paranoid delusions. Before becoming psychotic, Sam had been unemployed for a year and had a reduced social network. He became nervous

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when in contact with the public, following an episode eight years previously when he worked as a bank teller and had been held up at gunpoint by thieves, twice in two weeks. Sam resigned soon after the robberies because of his continued fear in the workplace. No counselling was offered by his employer. Subsequently, he became socially isolated and started abusing alcohol and, later, cannabis. Although he worked for brief periods as a computer operator, he was unable to maintain any job commitment. He avoided public places such as shopping centres and banks for fear of being exposed to harm again. During Sams recovery from his psychotic episode, his explanatory model was based on a vulnerability to psychosis resulting from the previous trauma. He experienced symptoms of post-traumatic stress disorder (flashbacks to the robberies) in the wake of his psychotic episode. Sam felt exposed, vulnerable and ridiculed after his psychotic episode, he was reminded of how he felt following the robberies. The COPE agenda was widened to include discussion of the trauma resulting from the robberies because the psychosis triggered the release of the posttraumatic stress symptoms; that is, the primary illness of psychosis triggered a response to the secondary condition. Through a broader focus, positive adaptation was developed and worsening of secondary morbidity was prevented. The vulnerabilitystress model suited Sam well. He realised he had removed himself from some aspects of his world following the robberies and had become increasingly asocial and suspicious of peoples intentions. This development, he believed, had made him vulnerable to psychosis. Sam also believed that the psychosis was an event which enabled him to review his life and make changes. Through COPE, Sam was encouraged to discuss his fears and then use graded exposure and systematic desensitisation.

Behavioural methods: Action COPE Behavioural interventions can be used to treat secondary morbidity. For example, the patient might be fearful of going to the local shopping centre but be unable to explain the problem. The therapist can assist by accompanying the person to the shopping centre, and exploring what it is about the centre that is troubling him or her and whether this fear is preventing him or her from engaging in other activities as well. Patients are often able to articulate their concerns immediately in these circumstances, thereby providing an opportunity to directly challenge the irrational views on the spot, suggest other interpretations and ask about other explanations for what is happening. This articulation can be a very effective technique for resolving the anxiety and maintaining therapeutic rapport. This process is termed Action COPE because the therapist and patient are involved in doing problematic activities together. The objective is to have normal and pleasant reallife experiences and provide rational interpretations of them. Four-column technique Beck et al. (1979) described the four column cognitivebehavioural technique that is useful when a patient is experiencing anxiety, depression or isolated incidences of reduced confidence. It can be particularly effective for patients who are prone to misinterpreting situations or are fearful of how people might respond to them after hospitalisation.

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In the four-column technique, emphasis is placed on the importance of thoughts in producing emotional and behavioural consequences. The therapist educates the patient about automatic negative thoughts and assists in identifying them, in order to explain why the emotion has arisen in the absence of obvious thoughts. To assist in recognising automatic negative thoughts, it might be useful to say: An automatic thought has usually occurred when you find yourself feeling unpleasant or having negative feelings. When you find youre feeling unhappy in a situation or social interaction, ask yourself: What do I think about myself? What do I think about the other person? What do I think about the situation?

This technique can be used in sessions and as homework. The patient is requested to highlight an activating situation or event, and then to record beliefs about this event, his or her feelings and the consequences of the feelings. Through this process the negative and often stigmatising thoughts about the event are uncovered. Once these thoughts are identified, it is possible to assist the patient in changing or modifying the thinking process to focus instead on the facts of the situation, and to replace irrational thoughts with rational thinking. Thoughts that are unhelpful and have no evidence are challenged and replaced with more-helpful thoughts for which evidence can be found. This process can be achieved by asking, What is the evidence for that? and then using hypothesis testing, whereby the patient is encouraged to offer other explanations. Figure 4 Daily record of dysfunctional thoughts (from Beck et al., 1979, p. 165)

Date

Event/Situation

Feelings/Emotions

Cognitions/Automatic thoughts What automatic thoughts preceeded the emotion?

Rational response

Describe: 1. Actual event leading to the emotion

Write rational response to automatic thought.

Another useful prompt to generate alternative interpretations might be to ask, What is another way of looking at it? In this way the therapist attempts to enlarge the patients perspective by assisting him or her to explore other options. In the case of a patient who is unable to shift from an irrational interpretation of a situation, the therapist can consider another angle and explore the notion So what if it happens?. He or she can assist the patient to formulate and practise coping plans, either during the session or in real life.

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Case example Four-column technique Tina, a 19-year-old apprentice chef, was admitted to a hospital because of her psychotic illness. Six months before the admission, she had become increasingly distressed, and believed the neighbours were spying on her and talking about her. She believed they could read her thoughts and put thoughts into her head. Three months before admission, Tina began hearing voices saying she was a bad person. She requested sleeping pills from her general practitioner in an attempt to escape from the voices, which were disrupting her sleep. Tina also noticed she had become disorganised and was unable to attend to her usual daily routine. She acknowledged she needed help, and again visited her general practitioner to request relief from her symptoms. Tina was an in-patient for two months and was initially treated with the antipsychotic medication chlorpromazine. A month after discharge, Tina returned to part-time work in a restaurant. It involved late nights, and after work, Tina and her co-workers usually went out to a cafe to relax and socialise before going home. However, she felt very uncomfortable at work and in social situations, and felt that her friends were staring at her. This feeling led to increasing anxiety, withdrawal and social avoidance. The therapist explored Tinas thoughts about why she felt awkward around her friends and work colleagues. She expressed concerns about her reduced confidence and self-esteem since hospitalisation, and had a sense of fragility. Her greatest fear was that people would think she was tainted because she was admitted to a mental hospital. The goal of treatment was to reduce Tinas social anxiety so she could function confidently and be content again within her community. The therapeutic approaches used were the four-column technique and role-play. Through the four-column technique her thinking process was examined and the relationship between thoughts, emotions and behaviours was highlighted. Role-play enables anxious people to pre-empt situations and practise their responses. Using the four-column technique, the therapist determined that Tinas activating event was walking into a cafe and seeing her friends stare at her. Tinas belief was My friends dont like me any more because they think Im loony. The consequential feeling was a rush of anxiety and inability to enjoy herself in the cafe. This resulted in her deciding not to go to the cafe after work. The initial task was to help Tina feel comfortable with her friends. This outcome was achieved by looking at her thinking and considering other rational hypotheses, whereby she was assisted in becoming more involved socially with her peer group. Graded tasks were useful, such as encapsulated in the following dialogue. Tina: Therapist: I dont enjoy being around people that much any more. Do you feel like this around everybody, or around just some people? Its really only when Im around some of my work friends. How do you feel when youre with these people?

Tina: Therapist:

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Tina: Therapist: Tina:

I feel like they dont want me there. What gives you that impression? I dont know exactly ... Its just a bit overwhelming, seeing everyone again. What do you think about when you see everyone again? I think they think Im a loser. What do your friends do or say that gives you that message, that youre a loser? Well, its hard to say, but some people look awkward around me. Could you explain that to me? Well, Bob doesnt chat much. Does he do this just with you, or with everyone? Bobs a bit shy; hes like that with most people. So, if Bobs like that with most people, it then makes sense that hes going to be like that with you too, doesnt it? Yes, I can see that now. Maybe youve been interpreting events when youre with your friends in a negative way, whereas actually, people are treating you just the same as usual. Possibly. Maybe you could try to identify your thoughts when youre around your friends, and we can closely examine them to see how youre interpreting events that happen around you. Okay, that sounds good.

Therapist: Tina: Therapist:

Tina: Therapist: Tina: Therapist: Tina: Therapist:

Tina: Therapist:

Tina: Therapist:

Tina:

The same activating event walking into the cafe and seeing her friends stare at her now had an alternative belief associated with it, such as, Theyre concerned, and happy to see me back at work and well again. The therapists next task was to slowly explore the issues of stigma and in doing so enable Tina to develop a less negativecatastrophic view of her episode of psychotic illness.

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The four-column technique is most useful when used over a period of time, for example as ongoing homework that is reviewed in therapy sessions. It takes time for people to learn and then understand the relationship between thoughts, feelings and behaviours. Role-play can be used to reinforce the four-column technique by assisting the patient to formulate and practise coping plans. The aim is to shift patients belief systems by recognising that thoughts are just one of many possible interpretations and outcomes of an event. Coping strategies Coping strategies are a useful safety net for patients who have secondary morbidity. Methods include distraction, relaxation training, stress management and help-seeking skills. Role-play can be effective for practising how to handle situations that cause anxiety.

Case example Role-play Sandra spent three weeks in hospital after a psychotic episode. She was reluctant to make a phone call to her friend Anne because she feared Anne would not want to see her again. In the role-play technique, Sandra and the therapist were involved in taking on different roles while in therapy and conversing as if in that role. Sandra played Anne, and the therapist played Sandra. The aim was to shift the patients belief system by assisting her to recognise that her thoughts were merely one of many interpretations of an event. Through this technique, a patient can often be given the style of dialogue and courage to embark on a situation. For example: Sandra: Therapist: Sandra: I havent seen my best friend Anne since my discharge from hospital. Whats preventing you from contacting Anne? Shell think Im a loony and ask questions about hospital, and wont want anything to do with me. How do you know how your friend will react to you now? I just do. Have you discussed this before with Anne? No. Then how can you be so sure your friend will disown you? Because Ive been in a mental hospital! It seems you might be guessing about how Anne will respond if you were to call her. Yes. Would you like to see Anne again?

Therapist: Sandra: Therapist: Sandra: Therapist: Sandra: Therapist:

Sandra: Therapist:

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Sandra: Therapist:

Yes. How about we practise you calling Anne, and go over possible ways for you to handle her questions? Okay. You pretend to be Anne and Ill pretend to be you, and Ill call you on the phone. Okay? Okay. Lets start then. Hi Anne, its Sandra calling. Oh, hello, Sandra. Long time, no see! What have you been up to? Yes, its been a while since we caught up... But whereve you been hiding? Well, Ive actually been fairly stressed lately, and needed some rest and to sort myself out. What do you mean? I had a bad response from having too much marijuana. What kind of response? Well, I started to believe evil things and became paranoid. But Im Okay now. [No response.] Okay Sandra. Lets move out of those roles now. What did you think about that? Well, it seemed Okay. I dont think my friend would push too far to know the details, and saying I was stressed really sounded right. Did it seem like something youd say to your friend? Yeah, I think I probably could.

Sandra: Therapist:

Sandra: Therapist: Sandra: Therapist: Sandra: Therapist:

Sandra: Therapist: Sandra: Therapist:

Sandra: Therapist:

Sandra:

Therapist: Sandra:

Different responses can be explored through role-playing, and responses can be rehearsed. Through this technique, the patient can gain some confidence by exploring potential situations in advance.

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6. Reviewing therapy before completion

The termination phase can be difficult to work through. It reflects the end of a specific form of therapy and usually the end of a relationship with an individual therapist. As with all brief psychotherapies, it is important that patients are prepared for termination from the outset. In COPE, patients are given a clear message at the start that therapy is time limited. It also involves frequent review sessions for assessing progress and considering any necessity to stop therapy. For some patients, the therapist is the only person with whom they can talk about psychotic symptoms. Many other people in the patients life might be frightened away by such frank discussion. For some, struggling with psychosis can be a lonely experience, and to have an ally in this struggle can be a great relief. When the therapy ends, there can be a measure of pain associated with the separation, but it can be lessened by preparing for termination from the outset. This point can be emphasised when the therapist and patient formulate a time-limited agenda in the assessment phase. The purpose of time-limited therapy is not to cure patients of all their problems; rather it is to help individuals develop skills to manage and overcome further problems and challenges. The process of termination is a recognition that the patient has achieved an ability to deal with an independent existence, and it is an acceptance by both the therapist and the patient that progress has been made. Some patients can experience re-emergence of their symptoms that resemble a relapse, and can leave the therapist feeling that nothing was achieved. Perris (1989) states that this can be the patients expression of dependence on the therapist and/or the therapeutic process. Rather than be viewed as a failure, it could be viewed as being an opportunity for learning about the place of interpersonal stressors in the genesis of arousal and relapse.

6.1 Reinforcement
It is important to discuss hypothetical situations and to reinforce what has been learnt or understood from therapy that can be helpful. The therapist can point out that therapy has been used to help identify problems and provide skills for how to cope with situations.

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Techniques that can assist in completing therapy include the following. Consider models of attachment and personality structure to guide how termination might be handled by the patient. Use information gained throughout therapy for example the therapists taking leave to indicate how the patient reacts to separation. Assist the patient in summarising progress to date, whereby a sense of progress leading to individuation and separation can be reinforced. Consider individual emotional needs. Use this phase as a time to help the patient consolidate knowledge and skills. Empower patients by reinforcing the occassions when they have gone through difficult times and coped well. Encourage their independence, strengths and skills learnt in therapy. Recognise the emotions related to termination as being real and appropriate.

6.2 Relapse management and prevention

Relapse prevention is one of the primary tasks during the termination phase. It can involve reinforcement of the knowledge that has developed through therapy, and helping the patient develop a relapse-prevention plan. Relapse can be considered as being either re-emergence of psychotic symptoms or a significant worsening of symptoms after a period of relative stability. It is important that relapse be seen as an event that can be monitored for and potentially averted. Relapse is associated with more distress to the patient and family, and can provoke an increased awareness of personal vulnerability within the individuals explanatory model of illness. Topics that might be discussed during termination, as well as during the psychoeducation phase of therapy, include use of medication strategies to prevent relapse. Ultimately, the decision by a patient to stop medication has to be an informed decision backed by both research and clinical experience as well as by the individuals state. It can be a difficult judgement. On the one hand, medication can have side effects and be a continuing reminder of past illness; on the other hand, stopping medication can result in an increase in the risk of relapse, particularly at times of increased stress. Clinical experience suggests that patients who are about to relapse display characteristic signs or symptoms that patients and their families can monitor (Birchwood, 1992). Patients who have non-affective psychosis tend to display non-specific early-warning signs, which perhaps begin with a vague sense of irritability or dysphoria related to anxiety or depression. This can develop into fleeting and transient psychotic symptoms, then a clear psychotic relapse. This progression can take only two to four weeks. In affective psychosis, the symptoms typically appear as an emergence of the characteristic mood. It should be recognised that some patients display non-specific changes in mental state for brief periods without progressing to relapse, and that a number of relapses occur without obvious early-warning signs. However, according to the evidence, it is possible to help most patients become aware of early signs of relapse. Management of early affective symptoms or behavioural disturbances might result in modification, or even prevention, of some psychotic relapses, but this outcome remains controversial. By being aware of the earliest manifestations, patients have the choice of recommencing medication if required and remaining in control of the disorder instead of seeing themselves as the passive victim of uncontrollable forces.

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For example Relapse management and prevention: Robert Robert, a young man who had schizophrenia, experienced two relapses during treatment by his COPE therapist. On each occasion, his early-warning signs of relapse followed the same pattern as that of his initial prodrome, although shorter in duration. They included a period of anxiety and irritability followed by fleeting paranoid ideation before relapse. During exploration of the relapses, a more complex picture was revealed. Robert would become increasingly preoccupied by the need to work harder, would go without sleep in an attempt to complete various tasks and would become more irritable with members of his family. As he became more anxious and depressed, he would resume marijuana smoking in an attempt at self-treatment. Awareness of his cannabis use by his family led to more conflict, more arousal and more diminution in sleep. His therapist, having teased out some of these interactions, was able to discuss a number of areas in which he could intervene in what had seemed to be an inevitable progress. His beliefs about the need to work and go without sleep could be challenged, the use of marijuana as a way of controlling affective distress could also be challenged, and he could be provided with support in dealing with arousal within the family. At the very least, by being aware of this scenario, Robert was able to consider use of medication to protect himself from the effects of sleep deprivation and arousal.

For example Relapse management and prevention; Odette Odette was diagnosed with bipolar disorder after initially presenting with depression, and then experienced two brief manic relapses during her time with her COPE therapist. Odette and her therapist developed a step-wise scale in which her symptoms of relapse were covered, commencing from first noticing a change in her mood or behaviour, through to mania or depression. Odettes scale was idiosyncratic to her experience and consisted of 14 levels, or points. The aim was for Odette to monitor herself using her own objective scale in order to help her recognise when she was becoming high or low. Odette gave her family a copy of the scale, so they could help monitor her mental state. In a process of negotiation, Odette agreed she would resume medication if her score on the 14-point scale became 7 or more, a bargain she was able to keep. By monitoring her progress, Odette was able to recognise the potential warning signs of relapse on two more occasions. Once, approaching exams, she had gone without sleep and pushed herself harder to complete assignments. By paying attention to the correlation between her life events and the higher score on her scale, she was able to accept that working harder could be counter-productive by leading to relapse and withdrawal from her course.

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