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Making Inroads Into Early Psychosis Treatment

Improving sense of self through environmental context manipulation

Vol. 25 • Issue 17 • Page 28

[ Editor's note: This is the second installment in a two-part series that began July 20. Part one is available here.]

Occupational therapists play a unique role in the treatment of early psychosis and substance abuse as the only professionals to explicitly use engagement in occupation to support participation in context as a targeted outcome. By modifying contexts and/or activity demands; teaching performance skills; and/or helping to develop effective performance patterns, OTs help clients develop positive identities and an ensuing sense of hope that allows them to achieve their highest possible potential.

Research-based Approaches

Researchers are implementing new programs that identify and treat early psychosis and substance abuse together.1Edwards et al.23describe the Cannabis and Psychosis (CAP) Project approach used to treat cannabis abuse within the early psychosis population at the Early Psychosis Prevention and Intervention Centre (EPPIC) in Melbourne, Australia, as based on the premise of harm reduction. They describe the harm minimization framework as "a non-judgmental and non-confrontational approach that promotes open discussion of cannabis use" (p. 287).

Addington25describes the approach used at the Early Psychosis Treatment and Prevention Program in Calgary, Canada, as devoid of the use of disapproval or moralizing. Rather, the program targets the behavior as something that could potentially cause sustained illness and interfere with recovery.

Start Over and Survive (SOS), from the University of Queensland, Australia, focuses on brief motivational enhancement through highlighting the discord between the way young people want to see themselves and the substance-user persona.26

In general, these approaches are non-confrontive, non-judgmental and behavior-based, with a focus on increasing motivation to reduce or end substance use in order to reduce the severity and duration of active psychotic symptoms and prevent relapse.

Ryff27proposed that there are six dimensions to psychological well-being: self-acceptance, positive relations with other people, autonomy, environmental mastery, purpose in life and personal growth. Environmental mastery and autonomy are stable in healthy individuals and consistently increase as they age from early adulthood to midlife. The onset of psychosis has the potential to destabilize and possibly even decrease growth and achievement in these areas, replacing well-being with psychological imbalance and dysfunction.

OT-specific Input

In the OT literature, Christiansen29,30echoes the importance of these dimensions and emphasizes the impact of deficits in relation to identity formation. Christiansen pre-supposes four statements about identity formation:

• Identity is an overarching concept that shapes and is shaped by our relationships with others.

• Identity is closely tied to what we do and our interpretations of those actions in the context of our relationships with others.

• Identity provides an important central figure in a self-narrative or life story that gives coherence and meaning to everyday events and life itself.

• Because life meaning is derived in the context of identity, it is an essential element in promoting well-being and life satisfaction.

Christiansen conceptualizes identity formation as occurring through our occupations in context. Successful occupational performance enhances self-efficacy which, in turn, helps develop positive identity. Failure to complete our chosen occupations is increasingly the case with the onset of psychosis. Christiansen29states, ".any threat to our ability to. present ourselves as competent people becomes a threat to our identity" (p. 553).

Wilcock32introduced the concepts of "occupational deprivation" and "occupational alienation" as ways to describe what happens to disadvantaged individuals or populations when they are denied meaningful occupation. Deprivation occurs from a lack of access to meaningful occupations, while alienation refers to feelings of estrangement from meaningful occupations. Individuals experiencing psychosis may show symptoms that cause others to limit opportunities for meaningful occupations due to fear or misunderstanding. People with psychosis also may experience occupational alienation due to the cognitive distortions that occur with the onset of psychotic symptoms.

Christiansen28says that one way to avoid potential rejection by society is to avoid social relations in the first place. Substance abuse masks one's identity. Substance abuse also replaces healthy occupations when they are lost to occupational deprivation or alienation.

Case Study

Historically, treatment for psychosis focused on reducing stress by eliminating expectations, thus reducing symptoms, because it was believed that individuals with mental illnesses lacked competency to manage even their own day-to-day lives.33But research has shown that they can manage by working toward graded, self-chosen goals within best-fit environments that change the context of their efforts.

"Albert" first entered OT services at age 17. His prodromal symptoms had not been identified, but he was referred to an early psychosis program within one month of the beginning of outright psychotic symptoms: paranoia that others were plotting to harm him, and delusions that there was a widespread plot by other males around him to "come on to him sexually" and that he could hear their "sexual thoughts."

Albert had been on antipsychotic medication for approximately two months with a subsequent decrease in the psychotic symptoms. He had been attending an alternative school, having been suspended from his public high school for behavioral issues and use of cannabis and alcohol. Those things were most likely his prodromal symptoms. An OT who specialized in treating early psychosis and substance abuse consulted with the team reviewing Albert's individualized education program (IEP).

The team was having difficulty determining the best approach to take with Albert. Its members concluded that Albert was not likely to pass his general education development (GED) tests due to consistently poor scores on predictor tests. In fact, the IEP team was debating having Albert drop all his academic expectations in order to focus on basic life skills.

The OT discovered that the environment in which Albert had taken his predictor tests did not mesh with his needs as determined by his Adolescent/Adult Sensory Profile. The OT suggested that Albert be given the opportunity to try studying for his GED at the local community college, where he would be surrounded by older young adults who were there by choice.

Albert began studying in the local community college's GED lab, which included small semi-private study rooms in addition to larger classrooms. He was set up with a standard study plan that included alternating between two subjects at a time, attending one-hour classes on each subject four days per week. In addition to the classroom instruction, Albert was scheduled to study for two additional hours each day in the independent study lab.

He was initially very motivated, fulfilling his commitment and stopping all substance abuse, but his motivation began to decline due to slow progress. The OT suggested that Albert focus on one subject per term, but Albert instead decided to take a term off to decide whether he wanted to continue pursuing the GED.

Albert initially improved during his term off while he worked full-time at a store his family owned; but his substance abuse eventually returned, as did his psychotic symptoms.

At the beginning of the next term, the OT assisted Albert in returning to GED study with a focus on one subject at a time. This time he saw more significant progress. Albert renewed his commitment and reduced his cannabis and alcohol use. He continues to make solid progress toward his GED by studying one subject at a time and using quiet, semi-private study areas rather than large classrooms with many distractions from peers his own age.

The move to community college enhanced Albert's positive social relations by surrounding him with others who were voluntarily participating in GED preparation. Albert gained autonomy by using a combination of classroom teaching and independent study. The OT enhanced the client's environmental mastery by grading the activity demands, e.g. having the student focus on one subject at a time. Albert now felt he could achieve his goal of obtaining a GED, a goal that both he and his father had identified as important.

Taken as a whole, OT intervention helped the student build a positive identity as a productive, competent student rather than as a high-school drop out, thus reducing his need to resort to substance abuse.

By intervening early, OTs can help individuals resume a more typical developmental path despite the onset of psychotic symptoms and co-occurring substance abuse.

References are available at or upon request.

Sean Roush, OTD, OTR/L, is a therapist at the Yamhill County Abacus Program in McMinnville, OR, and at the Early Assessment and Support Team at Mid-Valley Behavioral Care Network. He is also an adjunct faculty member at Pacific University School of Occupational Therapy.


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