Outreach and Engagement for Early Psychosis

At his best, Michael loves listening to classic rock, playing guitar and beating everyone he plays in chess. However, for two years, he’s been hearing voices telling him that people don’t like him, and that he’s a failure. His grades have dropped, and he has retreated from family and friends.

When his parents helped him seek mental health treatment, he only felt more defeated. He believed there was nothing he could do to stop the voices, so, he should just forget about any plans he had for the future. Both he and his parents felt hopeless about any chance of return to the life he had always wanted.

Michael’s story is not unique. Experiences such as voices, visions or beliefs that “no one else understands me” can be scary and isolating. Treatment can have little appeal and feel highly stigmatizing. Recovery-Oriented Cognitive Therapy (CT-R) is an evidence-based approach that skirts these (and many other) common challenges of working with young adults who have psychosis.

CT-R involves a set of procedures that capitalize on strengths, maximize resilience and promote recovery. The goal of CT-R is to strengthen a person’s “adaptive mode” (when a person is at their best) and neutralize or diminish their “patient mode” (when they are struggling with stress, access to energy and motivation). This effective therapy includes at least three key steps:

Step One: Access and Energize the Adaptive Mode

“When and what are they like at their best?” This question is the gateway to engaging a person’s adaptive mode. Shared experiences with members of their community or family, hobbies or passions, even relationships with animals or pets—these can offer glimpses into what makes a person truly happy. Michael’s therapist, for example, asked his family about when they saw him more energized and happy. She learned that Michael liked to play chess with his brothers and taught himself how to play guitar using YouTube videos.

This offered a window for the therapist to inquire about chess, and she even asked Michael to help her understand the rules of the game. Michael, in the position of teacher, helped equalize his relationship with the therapist and strengthen their connection. So, during games, he had noticeably greater energy. Asking for advice about a common interest is another effective way to access and energize the adaptive mode.

Step Two: Develop the Adaptive Mode through Aspirations

While learning to play chess, Michael’s therapist asked if there were other activities Michael would like to do. This allowed Michael to imagine and share his long-held desire to teach music. The therapist asked what would be the best part of teaching music to other people; Michael answered that it would be helping people feel good and do things they didn’t know they could do. Together, Michael and his therapist then started thinking about ways Michael could help people and meet the same meaning of teaching music every day.

Aspirations give a common goal that individuals, providers and families can work toward together as partners. Meaningful aspirations are motivating and can help develop the adaptive mode and a powerful sense of hope. Exploring the meaning of an individual’s aspiration and helping them to imagine it, is a great way to produce more energy, connect and realize the life they want.

Step Three: Actualize the Adaptive Mode with Action, Success, and Belief Change

Breaking aspirations into clear steps that an individual can then successfully achieve shows a person that they can get what they want from life. Family and friends can help by drawing the individual’s attention to their successes and what those successes mean. For example, as the therapist improved at chess and remembered more of the rules, she asked Michael: “What does it say that you taught me to play chess and now I'm this good?”

They also noticed that Michael wasn’t responding to voices while teaching. So, she would ask:

• “It seems like you’re less stressed when we’re doing this, what do you think?”
• “If it feels better, do you think we should do it more?”
• “It seems like you choosing to play chess with me gives you some control over the stress, is that right?”

Throughout each stage, the therapist helped Michael strengthen his own beliefs that he does have control over his voices, it is worthwhile for him to engage in activities and he can connect with others. Changing those beliefs Michael held about himself led to greater hope that his dreams were possible, and he successfully took action to realize them. He joined a chess club at school and made a friend in the club. He then taught his new friend how to play guitar. Being less focused on the voices in his head also led to improved grades. And Michael began planning for college and dreaming of a career as a teacher.

Michael’s success at getting into the flow of the life that he wanted is one example of what recovery can look like. Recovery-Oriented Cognitive Therapy provided understanding, framework and an appealing course of action so his therapist could collaborate with him to actualize the progress he wanted to make. Though challenges might initially seem insurmountable, families and providers should take reassurance that they can—and will—succeed.

Ellen Inverso, Psy.D. is the Director of Clinical Training and Education of the Beck Recovery Training Network at the Aaron T. Beck Psychopathology Research Center. She also provides training and consultation to mental health care providers in Recovery-Oriented Cognitive Therapy (CT-R) for individuals with serious mental illness. She is actively involved in collaborative efforts to infuse recovery into large systems of care and has developed innovative and transformative strategies for implementing CT-R on inpatient psychiatric units, in community residences and forensic facilities, and on assertive community treatment teams.

Paul M. Grant, Ph.D. is on the Faculty at the Aaron T. Beck Psychopathology Research Center, Perelman School of Medicine, University of Pennsylvania. Dr. Grant has devoted his career to developing new understandings of schizophrenia designed to dramatically improve the lives of affected individuals and their loved ones. In conjunction with Dr. Aaron T. Beck, Dr. Grant is the co-developer of recovery-oriented cognitive therapy and has conducted the basic science, and clinical trial to validate it. He also has designed overseen large-scale implementation efforts for the treatment approach.

Note: The case discussed in this blog is loosely based on actual cases and does not relate to any specific patient or contain any protected health information.