Kim T. Mueser, PhD

VanMeter and Cichetti define resilience as “a dynamic developmental process that encompasses an individual’s capacity to adapt positively following significant adversity.”

 While some researchers have conceptualized resilience as 

 many clinicians and researchers view it as a multidimensional and transactional process unfolding across the lifespan. When considering resilience in individuals recovering from a first episode of psychosis (FEP), it is important to remember that this condition usually develops over an extended period of time and culminates in a psychotic disorder that may further languish for months or even years before proper treatment is procured. Even when effective treatment for FEP is obtained, it rarely eliminates all the symptoms and dysfunction. Individuals are still left struggling to cope with an often chronic and unpredictable illness and, while trying to make sense of their experiences, they must struggle to put their lives back together as best as they can. Therefore, understanding the nature of resilience in individuals with FEP is a uniquely complex undertaking.

Researchers have found that resilience in individuals with FEP is 

 While there is no single measure of resilience, certain findings can help clinicians better understand resilience in this population. First, resilience is associated with greater improvements in functioning for individuals with FEP as well as with multiple-episode psychosis.

 Furthermore, no strong evidence suggests that individuals with FEP are more or less resilient than those experiencing a more prolonged course of schizophrenia. Second, little evidence indicates that greater resilience is associated with less severe positive symptoms. Conversely, resilience does appear to be related to negative symptoms and mood difficulties, meaning that higher resilience is associated with lower negative symtpoms.

 This evidence suggests that targeting resilience could improve functioning. Similarly, it shows that improving mood and reducing negative symptoms could promote resilience. While pharmacological treatments target positive symptoms, treating negative symptoms requires interventions that address mood, negative emotions, and motivation.

Recovery from FEP can mean more than reduction of positive symptoms. It also offers an opportunity to cultivate resiliency. Early intervention programs such as NAVIGATE, which incorporate strengths-based and resilience-focused principles, are anchored by the view that recovery transcends the alleviation of symptoms and aims at the experience of positive emotions, satisfaction, and promotion of 

 A core intervention component of the NAVIGATE program is Individual Resiliency Training (IRT).

IRT is a module-based approach to treatment that specifically aspires to promote self-efficacy and self-determination, hope for the future, meaning in life, and personal well-being in the context of teaching information and 

 Modules within IRT—and the NAVIGATE model more broadly—foster resiliency in individuals with FEP by providing guidance and training in numerous areas: enhancing positive emotions; cultivating an internal locus of control through shared decision-making; increasing cognitive flexibility and adaptive coping skills; increasing a sense of meaning and purpose through motivational enhancement and collaboration with natural supports (eg, relationships within family, school, work, and community environments); and fostering growth through cultivating a framework for understanding and processing the psychotic episode.

Throughout IRT, modules help patients develop their own personal resiliency story. This narrative of cultivating resilience is woven across the standard and individualized modules and creates opportunities for individuals to identify their own resilient qualities, highlight past personal stories of resiliency, build resilience through enhancing personal strengths, and identify the good things that happen every day.

 Similarly, these modules foster growth and resiliency by helping the patient to process their psychotic experiences and learn positive coping strategies.

The concept of resiliency in IRT is based on the broaden-and-build theory, which posits that the experience of positive emotions broadens an individual’s awareness, increases their cognitive flexibility, facilitates adaptive coping strategies, counteracts negative emotions, and encourages novel and exploratory thoughts and actions. Together, this leads to increased resources and opportunities to 

 Based on positive psychology interventions, the skills and strategies learned in IRT emphasize a behavioral approach, which increases the experience of positive emotions and focuses on building gratitude, prolonging pleasure through savoring, enhancing positive relationships, increasing kindness, and improving well-being.

Integrating Resiliency Into Clinical Practice

The implications of incorporating resiliency strategies into treatment could be wide-reaching. Environments that foster self-determination may promote motivation, well-being, and overall growth in 

 We will discuss 3 opportunities to build resiliency and self-determination within clinical encounters: shared decision making, establishing and following up on goals, and incorporating strengths into treatment.

Shared decision making is critical to empowering individuals with mental illness to become knowledgeable and participate in managing their illness.

 In the NAVIGATE model, prescribers use shared decision-making to select medications based on 

 This approach promotes autonomy and supports resiliency by facilitating choice, hope, and collaboration.

 The shared decision-making process begins by including the individual in the treatment discussions. During the process, practitioners should encourage opportunities for individuals to express their concerns about treatment, learn and discuss treatment options, ensure that patients are happy with the treatment decision, and provide time to review the treatment decision.

By identifying goals and taking the necessary steps toward achieving these goals, positive behaviors are fostered and meaningful outcomes become possible. In fact, the achievement of personal goals is associated with increases in 

 Practitioners provide opportunities for patients to reengage in their lives and promote recovery by developing goals that are personally relevant and challenging, and that focus on proximal outcomes. Patients have greater opportunities for recovery when practitioners provide ongoing feedback on goals that is structured and timely.

 In addition, clinicians who ask about and support goal progress promote self-efficacy in their patients and increase their expectations for success.

 In early-intervention treatment, clinicians can ask patients to share their goals, ask about progress toward a goal, or problem-solve a challenge or obstacle. Role-playing can help patients practice for success and increase their motivation to pursue a goal.

One of the best ways to foster resiliency is by building on existing strengths. Character strengths are defined as positive trait-like capacities associated with thinking, feeling, and behaving in ways that benefit an individual and others

 These strengths are associated with fulfillment and the pursuit of happiness, and they are a key feature of 

 The Brief Strengths Test can be used to assess character strengths, and it has successfully been implemented in IRT sessions with individuals with FEP.

 Ascertaining patients’ strengths can help make their relapse prevention plan more potent, by assisting them in identifying coping skills as well as crafting response strategies for early warning signs or triggers. These strengths can also foster engagement in healthy lifestyle strategies.

For example, if among a patient’s strengths is their ability to see beauty in nature, a helpful coping strategy could be taking a walk outside and paying close attention to the living things in the natural world. Since many coping strategies associated with character strengths have been compiled, clinicians can readily share these with their 

Additionally, character strengths can present opportunities to address difficulties and challenges, such as medication adherence.

 For example, if a patient’s strength is hope, the clinician can discuss how to cultivate a positive attitude about long-term mental health and explain how taking medication will contribute to their overall well-being in the future.

“Leroy” is a man with schizophrenia, aged 24 years. He struggles with delusional beliefs that the government is watching him and spying on him. He also hears voices that tell him he is a bad person and will never succeed in life. He currently lives at home with his parents and is a part-time college student. He is engaged in treatment with a coordinated specialty care program for individuals with FEP that includes therapy, supported employment and education, and antipsychotic medications. Leroy’s parents also participate in family education.

Leroy is currently participating in IRT with a therapist, who has begun IRT’s Assessment and Goal Setting Module. When Leroy completed the Brief Strengths Test, he identified his top 5 strengths as creativity, spirituality, love of learning, appreciation of beauty, and gratitude. Afterward, Leroy became increasingly paranoid about cars driving past his house; he began spending more time alone in his room, and he reported that the voices became louder.

In IRT, the therapist worked with Leroy to develop some coping skills to decrease his distress and support his goal of completing college. The therapist noted that listening to music and talking to a supportive friend are helpful coping strategies, and suggested that Leroy use one or more of his identified strengths to pinpoint other possible strategies. Leroy had discussed his interest in creative writing and exploring different religious beliefs. Thus, in collaboration with the therapist, Leroy developed a plan to try writing every day to engage his creativity. Leroy also said that he was interested in writing poetry and short stories about his spiritual beliefs and practices, which would engage his strength of spirituality.

When the therapist followed up in the next session, Leroy shared poetry he had written and was obviously engaged in the session when he did so. Although Leroy continued to struggle with paranoia, he noticed that the voices were quieter when he was writing. At the end of the session, Leroy decided to add writing as a daily coping skill that he could use to help him spend more time on his interests and less on his worries about the government. As Leroy’s symptoms improved, he decided to add a short-term goal about creating a collection of his short stories and poems to highlight his experiences with mental health symptoms.

Family members and supportive friends are another important resource for fostering resiliency. The connections that patients have to others promote strength and support 

 Individuals with FEP often live with their family members, who are in an ideal position to support their loved one’s resiliency. It is therefore important to teach family members positive psychology strategies. For example, the “good things” activity is an evening reflective exercise in which the patient lists up to 3 good things that happened during the day. For each good thing, the patient should identify the positive emotion associated with it and aim to determine why the good thing happened.

 When this activity is done daily, patients have an opportunity to establish a routine that they can share with family members and choose to continue voluntarily.

Clinicians can help family members identify their loved one’s character strengths, assess their own character strengths, and consider how those strengths could be helpful in caring for their loved one.

Lastly, family members can support a loved one’s goals by offering help, support, and encouragement, This is especially true for problem-solving obstacles. Clinicians can role-play strategies with family members and supportive friends to enable them to engage in productive conversations with the patient.

Traditionally, treatment for individuals with FEP has focused on the most common signs and symptoms of the illness, such as hallucinations, delusions, and difficulties in role functioning. However, there is an increasing awareness about the potential positive effects of interventions aimed at building resiliency. IRT is an example of a resiliency-focused treatment that includes an adapted positive psychology intervention. It has been successfully implemented in the NAVIGATE model for individuals with FEP. Fortunately, practitioners in early intervention programs can use some simple approaches to integrate resiliency strategies into treatment, including shared decision-making, recognizing and drawing upon character strengths, and supporting the pursuit of personally meaningful goals.

is a clinical psychologist and assistant professor in the Department of Psychiatry and Behavioral Sciences at the University of Minnesota Medical School. Her clinical and research interests include the development of psychosocial interventions for people with schizophrenia and early psychosis. 

is a clinical researcher in the Department of Psychiatry and Behavioral Sciences at the University of Minnesota Medical School and a doctoral student in counseling psychology at Saint Mary’s University of Minnesota. 

is a master’s-level licensed psychologist. She is a doctoral candidate in the Department of Family Social Science at the College of Education and Human Development, University of Minnesota, and teaches in the psychology department at St. Catherine University. 

is a clinical psychologist and professor at the Center for Psychiatric Rehabilitation at Boston University. Dr Mueser’s clinical and research interests include family psychoeducation, the treatment of co-occurring psychiatric and substance use disorders, psychiatric rehabilitation for serious mental illnesses, and the treatment of posttraumatic stress disorder.

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Articles

Simple but powerful strategies for drawing on patients’ existing character strengths and long-term goals. 

Promoting Resiliency After First-Episode Psychosis

Patients with severe mental illness (SMI), such as schizophrenia, bipolar disorder, and major depression, are more likely to have experienced trauma in childhood, adolescence, and throughout their adult lives than the general population.

 This high exposure to traumatic events such as physical and sexual abuse and assault takes a heavy toll. In addition to the immediate effects of victimization on an individual's quality of life, a history of trauma exposure in persons with SMI is associated with more severe symptoms, greater impairment of functioning, and higher levels of distress.

During the past decade, research has firmly documented that one of the most common consequences of trauma in patients with SMI is their high vulnerability to posttraumatic stress disorder (PTSD). The lifetime prevalence of PTSD in the general population is 8% to 12%

; in comparison, patients with SMI have much higher rates of PTSD, with most reported estimates ranging from 29% to 47%.

It has been hypothesized that PTSD mediates the negative effects of trauma on the course of SMI.

 For example, PTSD symptoms may directly exacerbate other symptoms of SMI. Or PTSD may indirectly worsen the course of illness through other problems related to PTSD, such as substance abuse, retraumatization, or a poor therapeutic alliance with treatment providers. However, despite the high comorbidity of PTSD in SMI, research and clinical services have only recently begun to address this problem.

In this article, we consider how comorbid PTSD can complicate the treatment of patients with SMI. Then we briefly summarize strategies for assessing PTSD in this population, and we describe treatment programs designed to address PTSD and related trauma consequences in patients with SMI. Finally, we discuss principles for integrating the treatment of PTSD and SMI.

Complicating issues of PTSD in the treatment of SMI

Trauma exposure and PTSD complicate treatment in patients with SMI in a number of ways. Exposure to trauma is associated with more hospitalizations and severe psychiatric symptoms, substance abuse, aggression, homelessness, and poor health.

 Engagement, diagnosis, and treatment of patients with SMI are all made more difficult by the failure, in routine psychiatric treatment, to recognize a history of trauma and PTSD. Studies that have systematically assessed PTSD in patients with SMI report that the disorder is document- ed in the charts of only a fraction of patients.

The underdiagnosis of PTSD has 2 important clinical implications. First, poor detection naturally leads to insufficient treatment of PTSD and continued distress for patients. Second, the failure to recognize PTSD may lead to misinterpreting PTSD symptoms as caused by another disorder. For example, mild hallucinations and delusions are relatively common in primary PTSD

 but can easily be mistaken for symptoms of schizophrenia. Similarly, the hyperarousal symptoms of PTSD (eg, autonomic arousal, hypervigilance, anger) can appear quite similar to the symptoms of hypomania or mania.

The presence of PTSD in patients with SMI can also hinder the development of a therapeutic alliance. 

describes most traumatic experiences as interpersonal in nature, which can lead to pervasive feelings of mistrust and difficulties with relationships. The working alliance between patient and clinician can influence the course of SMI.

 Thus, trauma-related interpersonal distrust may pose a challenge to establishing a good working alliance with patients with SMI and PTSD and may lead to suboptimal treatment.

Assessment of PTSD in severe mental illness

Traumatic experiences and PTSD can easily and quickly be assessed in persons with SMI through the use of standardized screening tools and assessment instruments developed for the general population.

 The greatest obstacle to accurately diagnosing PTSD is simply not using the standard techniques when asking about trauma. Avoidance of trauma-related stimuli is a cardinal symptom of PTSD. Consequently, if clinicians do not ask about patients' traumatic experiences, most patients with PTSD will not spontaneously divulge them. Clinicians' concerns about probing for traumatic life experiences are usually related to worry about exacerbating symptoms or disentangling reports of trauma from delusional beliefs.

Contrary to the concern that talking about traumatic events will worsen psychiatric symptoms, abundant clinical experience shows that this occurs only rarely. Rather, most patients with SMI readily tolerate inquiries about traumatic experiences, and many are relieved to talk about them. Concerns that reports of trauma in patients with SMI will be delusional are inflated. Reports have shown that, first, patients are more likely to underreport than overreport traumatic experiences. Second, rates of undiagnosed PTSD tend to be highest in patients with severe mood disorders, such as major depression or bipolar disorder (ranging from 40% to over 50%), and somewhat lower in patients with psychotic disorders such as schizophrenia or schizoaffective disorder (ranging from 25% to 35%).

Occasionally, clinical judgment is required to evaluate whether a patient's delusions stem from a genuine traumatic experience (eg, "I hear my mother telling me I am worthless even though she has been dead for 7 years"), or whether the traumatic events reported are themselves delusional or substantially distorted, such as those indicated by lack of coherence, implausibility (eg, "the librarian ran toward me and began to pummel me while the crowd simply stood by and watched"), or reference to supernatural phenomena (eg, alien abduction).

Research demonstrates that reliable and valid assessments of trauma history and PTSD can be obtained from patients with SMI.

 Furthermore, a history of trauma in a patient with SMI bears similar associations to PTSD as in the general population, such as childhood sexual abuse and number of lifetime traumas predicting a greater likelihood of PTSD.

 Tips for assessing trauma and PTSD in patients with SMI are summarized in 

Although substantial research has demonstrated effective psychotherapeutic interventions for PTSD in the general population,

 controlled trials have routinely ruled out patients with common features of SMI, such as psychotic symptoms, suicidal ideation and self-harming behavior, and cognitive impairment. The exclusion of patients with these problems from clinical trials has led to a call for interventions that can address the broad range of patients with PTSD,

Two approaches have predominated in developing programs for SMI. First, some interventions focus specifically on PTSD by adapting treatment approaches shown to be effective in the general population for patients with SMI, such as cognitive restructuring

 Second, some interventions are more broad-based and address a wide range of trauma sequelae, such as poor self-esteem and body image, dysregulated behavior, and problematic relationships.

 Pharmacological treatments are often included as important components of treatment.

The characteristics of several recently developed programs for trauma and PTSD in SMI are summarized in 

. Research on the effects of programs specifically developed to address trauma in patients with SMI is still in its infancy. However, clinical reports from early trials of these programs indicate that patients with SMI can be successfully engaged and treated, and that outcomes often improve.

 Only 1 randomized controlled trial of a treatment for trauma in SMI has been completed (K. T. Mueser et al, unpublished data, 2007). The results of the trial indicate that participation in the 12- to 16-week cognitive-behavioral therapy program was associated with improvements in PTSD symptoms, other symptoms such as depression, and trauma-related beliefs about oneself and the world. The following clinical vignette illustrates the use of this program.

Elizabeth is a 46-year-old woman with schizophrenia and PTSD. As a child she experienced significant physical abuse from her mother and, in an attempt to escape the abuse, frequently ran away from home. As a result, she spent much of her adolescence in a children's home. At 17, she left the home and moved in with her stepfather, who was separated from her mother. She lived with him for about a year, during which time he sexually abused her. At one point she became pregnant by him; she told no one, but suffered a painful and confusing miscarriage. Shortly thereafter, she withdrew from people and stopped taking care of herself, which was followed by signs of psychosis, including paranoia, hallucinations, and conceptual disorganization.

Elizabeth was hospitalized, treated, and discharged free of psychotic symptoms. She began to work as a store clerk, married, and had 2 children. Although her husband physically abused her, she remained fairly stable until he sought a divorce and took custody of their children. Following this, Elizabeth's condition worsened, and she spent several years cycling in and out of hospitals, interspersed with periods of homelessness. During a stay at a halfway house, she met a man and fell in love. Despite his drug abuse, they forged a relationship that lasted several years, during which time Elizabeth's symptoms and functioning stabilized, and she began working part-time. Then one day she found him dead, which was followed by a deterioration in her functioning.

Several years later, an evaluation confirmed that Elizabeth had severe PTSD. She reported that the death of her boyfriend was her most distressing traumatic experience. She said that she felt extremely guilty because she had not been able to prevent his death. She also talked about how her history of abuse made it difficult for her to trust anyone. The therapist described the 12- to 16-session treatment plan that included breathing retraining, psychoeducation, and cognitive restructuring to Elizabeth, who agreed to participate. Elizabeth was unkempt and restless but arrived promptly for all of her therapy sessions. Gradually, over time, she became more consistent in completing her homework.

The first session focused on teaching breathing retraining to manage her anxiety. During a homework review the following week, Elizabeth stated that she only felt comfortable practicing breathing retraining with her eyes open, but that she found it very helpful. The next 2 sessions focused on discussing the symptoms of PTSD, including how they differ from the symptoms of schizophrenia, and how the 2 affected each other. Elizabeth expressed relief in learning that her PTSD symptoms were common reactions to traumatic experiences.

During the fourth session cognitive restructuring was introduced. Elizabeth was able to understand the connection between thoughts and feelings but struggled with the related homework. She noted that she was afraid of becoming too overwhelmed when trying to do her homework alone. After more sessions in which the therapist helped her use cognitive restructuring to examine and challenge thoughts related to her upsetting feelings, Elizabeth began to practice using the skill on her own to deal with negative feelings. She described the therapy program as helpful and agreed to a joint session with her case manager at the end of treatment so that she and her therapist could teach her case manager the skills that Elizabeth had developed in therapy.

A recurring concern that was addressed with cognitive restructuring was Elizabeth's fear that nobody would claim her body at her death. She felt abandoned by her children, depressed and isolated, and preoccupied by worry about rejection. She was eventually able to identify several core beliefs, including the thoughts that "you cannot trust anybody" and "anyone that you do trust will abandon or mistreat you." Over the course of treatment she was able to recognize that there were some people who had stood by her (eg, her therapist, her psychiatrist, her case manager, her son). She was able to gain a more balanced perspective on her feelings of guilt over her boyfriend's death, realizing she was not to blame. As Elizabeth's symptoms gradually improved, she began to reach out to others. She started having brief conversations with people (eg, at the library), reconnected with a neighbor, and renewed her relationship with her son.	

Integration of PTSD and other treatment for SMI

There are several principles of effective treatment of patients with SMI and PTSD. Patient advocates, consumers, and trauma experts have argued that provider organizations usually require some degree of systemic change if appropriate services are to be provided for this common comorbid array. Such change, known as the implementation of trauma-sensitive services,

 entails provider and consumer education about trauma, general awareness of the needs of trauma survivors, and the introduction of the services that traumatized clients need and can best tolerate.

Accurate identification of traumatic life experiences and their consequences is critical in order to know which patients have PTSD and who would benefit from additional treatment. Patients who are motivated for treatment of PTSD need to be supported in undertaking that work. Such support can either be through directly working on PTSD in the context of the clinician's relationship with the patient, or by finding another clinician who can provide the treatment. In the latter case, the primary clinician can still play an important role by supporting the patient's participation in treatment and helping him or her review information and practice skills related to the program.

In addition, the pharmacological management of SMI should be sensitive to the nature of any PTSD treatment program in which patients are participating as well as to potential changes in needs over time. For example, some treatment programs for PTSD involve teaching skills for managing anxiety (such as breathing retraining or cognitive restructuring), suggesting that minimal and judicious use of benzodiazepines may be necessary in order not to interfere with learning those skills. With effective treatment leading to reductions in PTSD symptoms, depression, anxiety, nightmares, and hallucinations, many clients may require lower doses of medication or may be able to stop some medications altogether.

Trauma and PTSD are common in patients with SMI, but despite their impact on the course of psychiatric illness they are not routinely detected or treated. Advances during the past decade have shown that trauma and PTSD can be reliably and validly assessed in patients with SMI, and preliminary work suggests that specially designed treatment programs may also be effective. This progress bodes well for clinicians who recognize the importance and consequences of trauma in the lives of their patients with SMI and who seek treatment for PTSD and associated problems in this population. Given the building momentum in the field, there are good reasons to believe that clinical challenges such as psychosis, self-injurious behavior, or cognitive impairment will not be obstacles to effective treatment of PTSD in the future.

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Patients with severe mental illness (SMI), such as schizophrenia, bipolar disorder, and major depression, are more likely to have experienced trauma in childhood, adolescence, and throughout their adult lives than the general population. This high exposure to traumatic events such as physical and sexual abuse and assault takes a heavy toll.

Kim T. Mueser, PhD

Articles

Promoting Resiliency After First-Episode Psychosis

Integrating Psychosocial Treatment for PTSD and Severe Mental Illness