Promoting Resiliency After First-Episode Psychosis

VanMeter and Cichetti define resilience as “a dynamic developmental process that encompasses an individual’s capacity to adapt positively following significant adversity.”¹ While some researchers have conceptualized resilience as a trait fixed early in life,² 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 heterogeneous.³ 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.⁴ 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.⁴ 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.

Individual Resiliency Training

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 well-being.^5,6 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 skills for illness self-management.^7,8 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.^5-7

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.⁷ 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 build personal supports.^5,9 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.^6,7

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 patients.¹⁰ 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.¹¹ In the NAVIGATE model, prescribers use shared decision-making to select medications based on evidence-based options.¹² This approach promotes autonomy and supports resiliency by facilitating choice, hope, and collaboration.¹³ 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.¹⁴

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 well-being.¹⁵ 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.¹⁶ In addition, clinicians who ask about and support goal progress promote self-efficacy in their patients and increase their expectations for success.¹⁷ 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 (Table).¹⁸ These strengths are associated with fulfillment and the pursuit of happiness, and they are a key feature of positive psychology interventions.^19,20 The Brief Strengths Test can be used to assess character strengths, and it has successfully been implemented in IRT sessions with individuals with FEP.⁷ 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 patients.²¹

Additionally, character strengths can present opportunities to address difficulties and challenges, such as medication adherence.²² 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.

Case Example

“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.

The Importance of Family and Friends

Family members and supportive friends are another important resource for fostering resiliency. The connections that patients have to others promote strength and support self-determination.^23,24 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.^25,26 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.

Concluding Thoughts

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.

Dr Meyer-Kalos 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. Ms Coudray 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. Ms Williams-Wengerd 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. Dr Mueser 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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