Cognitively Oriented Psychotherapy for

First-episode Psychosis (COPE)

A Practitioner’s Manual

Manual 4 in a series of Early Psychosis Manuals

 Cognitively Oriented Psychotherapy
for First Episode Psychosis (COPE):
A Practitioner’s 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 Practitioner’s Manual. Melbourne: EPPIC.

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

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

PART 2: PRACTICE
1. Introduction..................................................................................................13
2. Assessment...................................................................................................15
2.1 Psychological assessment.......................................................................15
2.2 Strategies and techniques......................................................................18
2.3 Determining the agenda for therapy........................................................21
3. The therapeutic alliance..................................................................................23
3.1 Developing and maintaining the therapeutic alliance.................................24
3.2 Barriers to engagement.........................................................................27
4. Adaptation....................................................................................................29
4.1 Psychoeducation...................................................................................31
4.2 Vulnerability–stress model.....................................................................36
4.3 Identity work.......................................................................................39
4.4 Coping enhancement.............................................................................43
5. Secondary morbidity.......................................................................................45
5.1 Assessment..........................................................................................45
5.2 Strategies and techniques......................................................................46
6. Reviewing therapy before completion................................................................54
6.1 Reinforcement......................................................................................54
6.2 Relapse management and prevention.......................................................55

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.

iv
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 first–episode psychosis, and on the theory and practice described
in the literature about cognitive­­–behavioural 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 psychia-
trists). 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 experienc-
ing 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 cognitive–therapeutic 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 compre-
hensive 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 thera-
peutically 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.

vi
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 psychody-
namically 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 disap-
pearance 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 phe-
nomenon of the 15-minute outpatient-clinic ‘review’, which entailed assessment of the
patient’s 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 insta-
bility of maintenance effects (Hayes & Halford, 1993). In addition, ‘rehabilitation’
programs involved a narrow behavioural approach in which potentially helpful inter-
ventions 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 cognitive–behavioural therapeu-

tic 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 fam-
ily 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 para-
digms 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 model’s relevance to psychosis.

Brenner et al. (1992) supplemented this approach in a phase-oriented way with higher-
level cognitive–behavioural 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 cogni-
tive 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 psycho-
sis. 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’ psy-
chotherapy 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 symp-
toms. 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 moni-
toring 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 poten-
tial 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 impor-
tance 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 docu-
mented. 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 Organization’s

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 depres-
sion 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) sug-
gested 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 syn-
dromes. 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 clini-
cal research supports use of cognitive–behavioural therapy for depression and anxiety
disorders (DeRubeis & Crits-Christoph, 1988).

3.4 Psychological vulnerability

In the vulnerability–stress model (Zubin & Spring, 1977), a useful and practical sum-
mary 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 ori-
ented 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 hypoth-
eses 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 patient’s
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 pos-
sibility – 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 practi-
cal 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 resourc-
es (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 out-
comes, 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 non-
normative; exceeds the individual’s perceived ability to meet its demands; and disrupts
the individual’s 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 survivor’s 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 epi-
sode, 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 deter-
minants, 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 experi-
ence 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 personal-
ity 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 bor-
derline, depending on the pre-trauma personality and stage of ego development.

The influensce of the post-traumatic environment in shaping the survivor’s 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 under-
standing 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, help-
lessness, 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 one’s life more
generally
• An effort to raise one’s 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 disor-
der. The theory includes the suggestion that:

10 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 com-
plex 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 develop-
ment of a mature ‘sense of identity’ that occurs through interpersonal processes.

Erikson developed eight psychosocial stages from birth to middle age, thereby suggest-
ing 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 11

 constantly testing values, challenging the contradictions in their parents’ values, and
assessing the worth of alternative ideals and rules. Adolescents select values from vari-
ous sources in the process of determining their own.

Identity
Older adolescents look to other people in their environment and blend some of these
other people’s personality features with their own to develop a new identity. This iden-
tity is shaped throughout life as roles change, for example adjusting to becoming a
spouse, parent or worker. Outside forces such as peers, and the person’s 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 inti-
macy 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 opportu-
nity for adolescents to shape their identity by confronting questions such as ‘How do I fit
in?’ ‘What roles will I play?’ ‘What if I’m 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-psy-
chotic environment can disrupt the formation of the adolescent’s 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 dif-
ficulties 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 don’t.’ Problems
can arise if the post-psychotic adolescent starts to identify with people who are sick and
dependent.

12 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 patient’s explanation of his or her disorder and gain
an appreciation of the patient’s attitude towards psychosis in general. This involves
identifying the person’s current and potential problems, and formulation of factors
contributing to their cause and maintenance. These factors include strengths, weak-
nesses, 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 patient’s experiences and judgements about psychosis. The vul-
nerability–stress model is used, together with cognitive clarification, depending on
the patient’s 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 cognitive–behavioural therapy approach, therapy is carefully tai-

lored 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

13
 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.

14 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 encoun-
tered 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 approxi-
mately three sessions. The basis of the procedure is to assess the person’s 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 you’re
able to understand your experience and sort out any problems it
might have caused you.

Patient: Okay.

15
 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, we’ll look at this time in more detail. I’ll also ask you
some questions about your lifestyle, which will include job/school,
family, friends and your hobbies, so I can understand you better.

Patient: I can’t remember too much, though.

Therapist: That’s absolutely normal for you to have difficulty remembering

some events. If you wish, we’ll go over events to help prompt your
memory. Then we’ll define together an agenda or a list of things
you want to discuss during this time. From this list, we will choose
what we’ll discuss each week. How does this sound to you?

Patient: Okay.

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 acute–recovery 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?

16 Part 2: Practice
 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 patient’s admission or psychotic episode?
What was going on in the patient’s 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,
acute–recovery?
• What does he or she anticipate his or her recovery will be like?

Adaptation–identity

• How does the patient’s 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 patient’s 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 patient’s 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 patient’s 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?

Assessment 17
 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 patient’s family and friends describe his or her personality?
• Does the patient exhibit dependent, avoidance, schizoid, histrionic or borderline per-
sonality traits?
• How does personality and intellectual level impact on the patient’s ability to cope?

Therapeutic contract

• What does the patient want from therapy?

• What is his or her perception of the therapist’s 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 therapist’s job to convey an understanding of the patient’s
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 ration-
ale for meeting with a therapist. The therapist should acknowledge and understand the
possible trauma of the patient’s 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 develop-
ment 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 one’s understanding of their problems
without seeming to be rigid or commanding.

First, describe the general goals of therapy; then, elicit the patient’s 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 you’d 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?’

18 Part 2: Practice
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 you’ve been having difficulty arriving at our

sessions on time...

Alice: So?

Therapist: Could it be that it’s difficult for you to be here?

Alice: What do you mean?

Therapist: Well, could it be that you’re currently having a difficult time?

Alice: For sure!

Therapist: Would you like to tell me about that?

Alice: Well, I can’t stand being around my friends.

Therapist: Why is it difficult being with your friends?

Alice: They’re at university and I’m left out!

Therapist: This must be difficult and sad for you. How have you been left out
of things?

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.

Assessment 19
 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 patient’s 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 anti-
psychotic 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 patient’s limited responses, but having him
or her continue to ask questions in order to gain details or clarification of the patient’s
experiences. The therapist sets the scene so the patient believes the therapist is over-
whelmed, or somewhat simple or concrete, and therefore needs the patient’s 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 Samantha’s state:

‘From what you’ve been telling me, it seems like the last few months have been
somewhat chaotic and uncertain for you. But I’m finding it a bit hard to put all
the pieces of your picture together. Could you help me out a bit?’

20 Part 2: Practice
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 patient’s 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 patient’s 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 indi-
vidual needs and the therapist’s 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 demys-
tified. Being clear with the patient is important, because psychosis is usually a very
confusing and disempowering experience, and most people feel vulnerable in the post-
psychotic phase. The agenda can be the framework for containing therapy; that is, the

Assessment 21
 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 flex-
ibility 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, stalk-
ing 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. Jim’s 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 ration-
ale 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 threaten-
ing 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 moti-
vation and wanted to occupy his time. When he was probed some more he
reluctantly acknowledged that he missed his friends and wouldn’t mind seeing
them again, but that they probably weren’t interested in him anymore because
of his illness.

This led into a discussion of Jim’s views about psychosis, and to the therapist
suggesting that Jim needed some factual information about his illness. The inten-
tion 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, Jim’s agenda for therapy was:

• amotivation
• work
• social network – getting in touch with old friends
• Jim’s episode of psychosis – the facts.

22 Part 2: Practice
3. The therapeutic alliance

Assessment and engagement so that therapy can commence should begin as a paral-
lel 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 dif-
ficulties 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 impor-
tance of the therapist’s characteristics, and found that negative outcomes were associ-
ated with:
• lack of empathy
• underestimating the severity of the person’s 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 con-

scious 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 person’s
psychosis developed. The therapist is required to understand:
• the pervasive and individual effect of a psychotic episode on a person’s life
• the variety of reactions a person can have to the experience of psychosis

23
 • the person’s sociocultural milieu
• the person’s and carer’s initial attitudes to the services and treatments that are avail-
able.

3.1 Developing and maintaining the therapeutic alliance

A large body of literature exists in which the development of the therapeutic relation-
ship 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, sum-
marising, 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 proc-
ess that may take time to evolve. Perris (1989) warned that the therapist must avoid
being overcome by the patient’s negativity and passivity. The therapist must be aware of
the patient’s ‘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 patient’s cognitive and emotional function-
ing 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 therapy’s 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 patient’s true
feelings.

The therapist should actively show empathy and warmth, both verbally and behaviour-
ally. 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.

24 Part 2: Practice
 Case example
Being respectful of the person’s 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 acknowl-
edged that he had been experiencing a ‘rough time’ and needed assistance to get
through it. The therapist recognised the patient’s 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 experi-
ence 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 becom-
ing unwell and the illness’s effect on the person’s 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.

The therapeutic alliance 25

 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 you’re having some problems arranging your activities,

and that you’re finding it frustrating because you don’t get some
things done. I know I’d be lost without my diary – so maybe you’d
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 tak-
ing 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 antici-
pation of the patient’s 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 patient’s 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 patient’s efforts and initiative. The acknowl-
edgement 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 ses-
sion. The patient’s 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.

26 Part 2: Practice
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 patient’s 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 partici-
pate. 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 concentra-
tion. 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 patient’s 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 expe-
rience 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
patient’s 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

The therapeutic alliance 27

 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 accord-
ingly.

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 patient’s personality style and
the presence of any personality disorder. A thorough personality assessment is required
in order to assess the impact of these factors.

28 Part 2: Practice
4. Adaptation

Psychosis is often, but not always, experienced as a personal disaster and a highly dam-
aging 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 con-
cept 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 man-
aging 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 patient’s are aware of a significant change in their experi-
ence 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 devel-
oping a framework for adapting to the disorder. COPE is distinguished from other

29
 cognitively based therapies by virtue of its focus on the patient’s 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 person’s 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 person’s 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 patient’s 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 patient’s:

• 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 psycho-
sis, 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.

30 Part 2: Practice
4.1 Psychoeducation
Psychoeducation is an important strategy for reducing the distress and disability associ-
ated 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 individ-

ual 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 patient’s
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 mental-
health 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 diag-
noses. 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 illness’s 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 label-
ling 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 psy-
chotic 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

Adaptation 31
 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 patient’s 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 Melanie’s recovery, information about psychosis was

delivered in such a way that her current anxieties were relieved. She was reas-
sured 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

Melanie’s actual experience. The causes of her symptoms were discussed in terms
of her response to stress in conjunction with marijuana smoking. The descrip-
tions of her symptoms were used to highlight and understand a therapy-agenda
item entitled ‘What is psychosis?’. The length and course of Melanie’s illness
were used as the basis for discussing diagnostic issues and possible early-warning
signs of relapse, whereby discussion was prompted about Melanie’s vulnerability
to relapse.

During the acute phase, Melanie experienced difficulties with processing infor-
mation. The therapist used video material as a phase-appropriate vehicle for
commencing therapeutic work on psychoeducation issues, along with structured,
concrete discussions. Later in Melanie’s 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 individual’s under-
standing 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 explan-
atory model can be influenced as a result.

At the same time, it is important to present alternative explanations and coping strate-
gies. The therapist thereby enables an alternative model to be considered rather than
an unchallenged – and possibly stigmatising – illness model to become entrenched. The

32 Part 2: Practice
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 person’s 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 patient’s 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 per-
son’s 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 concen-
trate on the ‘negative influences’ of her past.

The therapist was left with a specific path to follow. Maria’s 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
Maria’s 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 out-
come 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: I don’t enjoy being around people that much any more.

Therapist: Do you feel like this around everybody, or around just some
people?

Maria: It’s really only when I’m around some of my friends.

Therapist: How do you feel when you’re with these people?

Maria: I feel edgy and uncomfortable.

Adaptation 33
 Therapist: Can you tell me more about those feelings?

Maria: I’m not sure I can ... it’s just a bit overwhelming, seeing everyone
again.

Therapist: What do you think about when you see everyone again?

Maria: I think they think I’m a loser.

Therapist: What do your friends do or say that gives you that message, that
you’re a loser?

Maria: Well, it’s hard to say, but some people look awkward around me.

Therapist: Could you explain that to me?

Maria: Well, Mike just says a few things to me and doesn’t talk much.

Therapist: Does he do this with just you or with everyone?

Maria: Mike is like this with most people, I think.

Therapist: 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?

Maria: I suppose so.

Therapist: I wonder if you’ve been interpreting events when you’re with your
friends in a negative way, when in fact your friends are treating
you just the same as usual.

Maria: Maybe.

Therapist: Maybe we need to explore this some more. It’d be useful for you
to try to identify your thoughts when you’re around your friends;
then we can look closely at your thoughts to see how you’re
interpreting events that happen around you.

Maria: OK.

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.

34 Part 2: Practice
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 person’s 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 destruc-
tive. 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 use-
ful way to access people’s explanatory models and mental-illness stereotypes and
normalise the experience.
• reading material from the book series Overcoming Common Problems, published
by Sheldon Press, London

Adaptation 35
 • 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 Vulnerability–stress model

Apart from providing a diagnosis or ‘name’ for a psychotic disorder, it is usually
helpful to present a model of the disorder’s underlying nature and how the disorder
came about. The vulnerability–stress 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 pro-
posed that each episode of psychosis is triggered by a ‘challenging event’ that exceeds
the individual’s ‘vulnerability’ threshold. They said that vulnerability could be acquired
or transmitted genetically, and was offset by the individual’s 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 psy-
chotic symptoms.
• Recognition of early-warning signs. Review the course of the illness from the pro-
dromal phase through the acute psychotic phase to the recovery phase; then exam-
ine the prodromal symptoms that were noticed first. Preferably do this in conjunc-
tion 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.

36 Part 2: Practice
• 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 early-
warning 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 influ-
ences otherwise at work in the patient’s situation.

For example
Vulnerability–stress 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 dis-
tracted 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 mother’s delu-
sions, 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 mother’s. 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 stress–vulnerability model was generated to assist Lucy in under-

standing her symptoms. Her genetic vulnerability to psychosis and memories of
her mother’s illness were discussed. Lucy’s general fear of losing her son and, like
her mother, of being helpless, were thereby revealed. It was important to high-
light the differences between her mother’s illness and Lucy’s illness, using psycho-
educational 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 Lucy’s auditory halluci-
nations 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 ill-
ness. 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

Adaptation 37
 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 stress–vulnerability 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 patient’s ‘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 psychot-
ic 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 Living with Losing job Date of hospital

relationship girlfriend discharge

Using cannabis Having car accident Date of hospital Current date

and arguing with parents admission

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

38 Part 2: Practice
 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 feel-
ing 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 sig-
nificant events.

The vulnerability–stress 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 ineffec-
tiveness 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 compensa-
tion. 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 giv-
ing 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.

Adaptation 39
 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 family’s courier busi-
ness 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 – Bill’s Grid

How do I see myself now?

Dependable 1 2 3 4 5 6 7 Not dependable

Healthy 1 2 3 4 5 6 7 Sick
Independent 1 2 3 4 5 6 7 Dependent
Trustworthy 1 2 3 4 5 6 7 Untrustworthy
Reliable 1 2 3 4 5 6 7 Unreliable
Motivated 1 2 3 4 5 6 7 Unmotivated
Happy 1 2 3 4 5 6 7 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 patient’s view. Irrational assumptions should be chal-
lenged 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 stress–vulnerabil-
ity 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.

40 Part 2: Practice
Figure 3 – Timeline: Perception of self

Before psychosis During psychosis Current self Future self

Open minded Frightened Introverted Knowledgeable about self

Generous Evil Reserved Outgoing
Outgoing Paranoid

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 sepa-
rate 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 confi-
dence, 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 people’s 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 real-
life 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 una-
ble 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 ill-
ness – he believed mental illness was a life sentence of instability, dependence and
rejection.

The therapist decided that Bill needed to experience acceptance and some auton-
omy again. Bill hesitantly agreed to accompany the therapist into the city, and

Adaptation 41
 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 ele-
ments 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 Kate’s 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 char-
acteristics through which her personality could be defined, then explored the
current existence of these traits. The therapist asked Kate to seek her family’s
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 cognitive–behavioural approaches such
as role-plays, the four-column technique (see the following section) and psycho-
education about the recovery phase and negative symptoms.

42 Part 2: Practice
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 ini-
tially 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 people’s expe-
riences. 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 vulnerability–stress 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 patient’s 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 patient’s name is written in a circle, and other circles are drawn around it, includ-
ing the names of family and friends. These names are placed closer or further away
from the patient’s name, depending on the quality of the relationship.

Using this technique is also a good way to explore and discuss stigma issues. For exam-
ple, 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 don’t 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 patient’s mental health and aid identification of
early-warning signs of relapse.

Adaptation 43
 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 person’s 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 person’s views about events and his or her involvement in them.
Some patients misinterpret events and judge themselves harshly in these circum-
stances. 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
someone’s 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.

44 Part 2: Practice
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 with-
drawal, 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 psy-
chosis; 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 exam-
ple, post-traumatic stress disorder might have arisen in response to events surrounding
admission and treatment of the psychosis. Flashbacks, nightmares and intrusive memo-
ries 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 sec-
ondary 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

45
 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 patient’s schemas

(thought processes). For example, depressive schemas can include the following.
• ‘My life has been irreversibly changed.’
• ‘I have no future now.’
• ‘I’m unlovable.’
• ‘I’ve lost my job; I’ll never work again.’
• ‘I’ll 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?’
• ‘They’re thinking I’m mental.’
• ‘They’re thinking I’m dangerous.’
• ‘They think I’m no good at my job now I’ve been in a psychiatric hospital.’
• ‘I can’t 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 patient’s
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 train-
ing 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 stres-
sors and be more aware of potential inner resources whereby greater independence and

46 Part 2: Practice
satisfaction with life are facilitated. Perris (1989) acknowledged that therapeutic tech-
niques 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 psy-
chotic 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 I’ll 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 ‘dis-
tancing’, 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 con-
valescence 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 hyper-
somnia is interfering with energy levels for everyday activities, the therapist might
respond by saying, ‘It’s 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 recu-
perate 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 sur-
rounding 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 inten-
sity 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 expe-

rience, 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

Secondary morbidity 47
 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 con-
tinued 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 shop-
ping centres and banks for fear of being exposed to harm again.

During Sam’s 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 rob-
beries) 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 post-
traumatic stress symptoms; that is, the primary illness of psychosis triggered a
response to the secondary condition. Through a broader focus, positive adapta-
tion was developed and worsening of secondary morbidity was prevented.

The vulnerability–stress 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 people’s 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 cen-
tre, 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’, sug-
gest 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 real-
life experiences and provide rational interpretations of them.

Four-column technique
Beck et al. (1979) described the ‘four column’ cognitive­–behavioural 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.

48 Part 2: Practice
 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 unpleas-
ant or having negative feelings. When you find you’re 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 nega-
tive 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 Rational response

thoughts

Describe: What automatic thoughts Write rational response

1. Actual event leading to preceeded the emotion? to automatic thought.
the emotion

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 patient’s
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.

Secondary morbidity 49
 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 per-
son. 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 gener-
al 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 uncom-
fortable 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 Tina’s thoughts about why she felt awkward around her
friends and work colleagues. She expressed concerns about her reduced confi-
dence 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 Tina’s social anxiety so she could func-
tion 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 Tina’s activating
event was walking into a cafe and seeing her friends stare at her. Tina’s belief
was ‘My friends don’t like me any more because they think I’m loony.’ The con-
sequential 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 hypoth-
eses, 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: I don’t enjoy being around people that much any more.

Therapist: Do you feel like this around everybody, or around just some
people?

Tina: It’s really only when I’m around some of my work friends.

Therapist: How do you feel when you’re with these people?

50 Part 2: Practice
 Tina: I feel like they don’t want me there.

Therapist: What gives you that impression?

Tina: I don’t know exactly ... It’s just a bit overwhelming, seeing
everyone again.

Therapist: What do you think about when you see everyone again?

Tina: I think they think I’m a loser.

Therapist: What do your friends do or say that gives you that message, that
you’re a loser?

Tina: Well, it’s hard to say, but some people look awkward around me.

Therapist: Could you explain that to me?

Tina: Well, Bob doesn’t chat much.

Therapist: Does he do this just with you, or with everyone?

Tina: Bob’s a bit shy; he’s like that with most people.

Therapist: So, if Bob’s like that with most people, it then makes sense that
he’s going to be like that with you too, doesn’t it?

Tina: Yes, I can see that now.

Therapist: Maybe you’ve been interpreting events when you’re with your
friends in a negative way, whereas actually, people are treating you
just the same as usual.

Tina: Possibly.

Therapist: Maybe you could try to identify your thoughts when you’re
around your friends, and we can closely examine them to see how
you’re interpreting events that happen around you.

Tina: Okay, that sounds good.

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, ‘They’re con-
cerned, and happy to see me back at work and well again.’

The therapist’s next task was to slowly explore the issues of stigma and in doing
so enable Tina to develop a less negative–catastrophic view of her episode of
psychotic illness.

Secondary morbidity 51
 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 patient’s 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: I haven’t seen my best friend Anne since my discharge from hospital.

Therapist: What’s preventing you from contacting Anne?

Sandra: She’ll think I’m a ‘loony’ and ask questions about hospital, and
won’t want anything to do with me.

Therapist: How do you know how your friend will react to you now?

Sandra: I just do.

Therapist: Have you discussed this before with Anne?

Sandra: No.

Therapist: Then how can you be so sure your friend will disown you?

Sandra: Because I’ve been in a mental hospital!

Therapist: It seems you might be guessing about how Anne will respond if
you were to call her.

Sandra: Yes.

Therapist: Would you like to see Anne again?

52 Part 2: Practice
 Sandra: Yes.

Therapist: How about we practise you calling Anne, and go over possible
ways for you to handle her questions?

Sandra: Okay.

Therapist: You pretend to be Anne and I’ll pretend to be you, and I’ll call you
on the phone. Okay?

Sandra: Okay.

Therapist: Let’s start then. Hi Anne, it’s Sandra calling.

Sandra: Oh, hello, Sandra. Long time, no see! What have you been up to?

Therapist: Yes, it’s been a while since we caught up...

Sandra: But where’ve you been hiding?

Therapist: Well, I’ve actually been fairly stressed lately, and needed some rest
and to sort myself out.

Sandra: What do you mean?

Therapist: I had a bad response from having too much marijuana.

Sandra: What kind of response?

Therapist: Well, I started to believe evil things and became paranoid. But I’m
Okay now.

Sandra: [No response.]

Therapist: Okay Sandra. Let’s move out of those roles now. What did you
think about that?

Sandra: Well, it seemed Okay. I don’t think my friend would push too far to
know the details, and saying I was ‘stressed’ really sounded right.

Therapist: Did it seem like something you’d say to your friend?

Sandra: Yeah, I think I probably could.

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.

Secondary morbidity 53
 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 termina-
tion 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 patient’s life might be frightened away
by such frank discussion. For some, struggling with psychosis can be a lonely experi-
ence, 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 patient’s 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.

54
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 therapist’s 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 diffi-
cult 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 help-
ing 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 individual’s explanatory model of illness.

Topics that might be discussed during termination, as well as during the psychoeduca-
tion 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 individual’s state. It can be a dif-
ficult 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 characteris-
tic 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 anxi-
ety 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 them-
selves as the passive victim of uncontrollable forces.

Reviewing therapy before completion 55

 For example
Relapse management and prevention: Robert

Robert, a young man who had schizophrenia, experienced two relapses dur-
ing 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 dis-
tress 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 depres-
sion, 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. Odette’s 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.

56 Part 2: Practice
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