Introduction to Counseling Young People Experiencing Psychosis

Mental health providers may ask, “What is the most effective model or intervention for people experiencing symptoms of psychosis?” The EASA Center for Excellence recommends that any can be effective if:

(a) The approach is individualized to the client’s needs and goals.

(b) The decision-making power in treatment is shared between clinician and client.

(c) The clinician solicits and welcomes feedback.

(d) The relationship/alliance between the provider and client is strong.

Relationship/Alliance is Key

Research indicates that therapy works when “clients experience the relationship positively, perceive therapy to be relevant to their concerns and goals, and are active participants” (Duncan, Miller, & Sparks, 2007, p. 39). In the words of a participant in the EASA Young Adult Leadership Council, “What helped me? Being able to tell my counselor what’s working and what’s not. Having a real conversation where I’m respected and heard.”

The client-clinician relationship is the most important component to counseling outcomes. Michael J. Lambert’s “common factors” research suggests that relationship account for approximately 30% of counseling efficacy – the highest of any controllable factor. When it comes to counseling young adults, relationship plays an even bigger role. The young adult age group has high drop out rates and make few visits in mental health treatment. Engagement for young adults is highest when they perceive relationship to be supportive, focused on their goals and decisions, and positive/recovery-oriented (Walker &Welsh, 2014; Duncan, Miller, & Sparks, 2007).

Importance of Individualization and Collaboration

No single model or intervention will meet the needs of every unique client. Instead, a general clinical best practice standard is to individualize the intervention. Optimal individualization can occur by asking the client about their preferences, soliciting feedback, and collaborate in decision-making (Walker &Welsh, 2014).This is no different for young adults experiencing psychosis. In fact, individualization andrespectful collaboration may be even more important for this group. Young adults are generallyexperiencing a complex developmental period in which they navigate several key tasks: deciding who they are and what they want from life, seeking independence, and forging a sense of self through experimentation and decision making (Benson & Elder, 2011, p. 11; Arnett, 2000, p. 472-474). Mental health services that are developmentally appropriate support the young person’s ability to accomplish these tasks by honoring their agency and autonomy.

Some young adultsmay come into therapy wanting to focus specifically on their psychotic symptoms. But others may want to talk about how to make more friends, or want assistance in filling out an application. It is important that the clinician listen and respect their client’s preferences, and view treatment planning as a collaboration.

Example Vignette

In Clarissa’s first session with her clinician, Ben, she didn’t mention that she had recently had her first psychotic episode. Instead, she talked about how hard it was talking to her boyfriend. “He doesn’t understand that I’ve found the meaning to the universe,” she said repeatedly. Ben could sense that “finding the meaning to the universe” was how Clarissa interpreted her episode as part of her explanatory model (a person’s beliefs and perceptions about their experiences). He also understood focusing on the issue that Clarissa wanted was important to building their relationship.

He asked Clarissa if she would like to generate some ideas for how to talk to her boyfriend. When she agreed, he led her in a Solution-Focused Brief Therapy (BFST) technique to help her brainstorm practical solutions. At the end, Ben for asked for her feedback on whether she thought the technique was helpful. Clarissa said it was.

The next session, Clarissa described how stressful it was to deal with her collegehomework. Ben worked with her to find the contact information for the Student Disabilities Office and helped her set up an appointment. Together they worked on strategies to make her homework manageable.

After more sessions, Clarissa started to talk about how much thinking about the meaning of the universe was overwhelming her: “I don’t want to keep thinking these depressing thoughts and seeing these connections everywhere.” Ben asked her if she was interested in Cognitive Behavioral Therapy (CBT) to help her manage the unwanted thoughts. She agreed. Through CBT, Ben and Clarissa worked together to reduce the amount of stress that Clarissa experienced due to her symptoms. Although Clarissa never came to believe she had a psychotic episode, she felt supported and more prepared to live her life the way she wanted.

This vignette illustrates how Ben listened to Clarissa, respectfully solicited her feedback, worked with her explanatory model, and adapted his approaches to fit her needs. He selected models and interventions that he thought would fit her goals. However, he made sure to ask what she thought of the interventions, and only proceeded with her permission.

The vignette also speaks to the importance of a clinician having a varied toolkit to draw from. There is a vast array of models and interventions available to clinicians. An overview of some is covered in “National Learning Collaborative: Introduction to Models and Interventions for Young People Experiencing Psychosis.”

References

Arnett. J. (2000). Emerging adulthood: a theory of development from the late teens to early twenties. American Psychologist, 55 (5), 469-480.

Benson, J.E., & Elder, G.H. (2011). Young adult identities and their pathways: a developmental and life course model. Developmental Psychology, 47 (6), 1646 – 1657.

Duncan, B.L., Miller, S.D., & Sparks, J. (2007). Common factors and the uncommon heroism of youth. Psychotherapy in Australia,13 (2), 34-43.

Duncan, B.L., Hubble, M. & Miller, S.D. (Eds.)(2010). The heart and soul of change: Delivering what works in therapy. Washington DC: American Psychological Association.

Walker, J., & Welsh, M. (2014). Empirically supported and promising practices for engaging young people and improving outcomes. RTC on Pathways to Positive Futures Webinar. Retrieved from