Psychosocial
Interventions for
Psychosis
Gemma Stacey
Aims

To gain an overview of the stress vulnerability model

To identify interventions adopted within this model:
 Coping skills enhancement
 Relapse prevention

Apply the model to practice based scenarios.

Consider how the model may inform your approach to
working with people with psychosis
What do you believe
causes psychosis?
Stress

It may be said that all life events cause
some degree of stress due to the
adaptation involved.

The Stress Vulnerability Model maintains people
who eventually suffer psychosis already had a
pre-disposition to the effects of stress.
What do we mean by stress?
Is it a physiological or psychological
reaction?
 Are there different types of stress?
 Does it effect every person in the same
way?
 What happens with short term stress?
 What happens with long term stress?

Stress and Stress Response
Actual Demand
eg work, child care, life
events
Actual Capability
eg health, resources,
coping strategies
Perceived Capability
Perceived Demand
Appraisal
(How well we think we are doing)
Imbalance = Stress
Physiological
Response
Lazarus & Folkman (1984)
Psychological
Response
Behavioural
Response
What do we mean by vulnerability?

When you think about people you have
worked with, what factors do you think
make them vulnerable to stress?
Stress Vulnerability Model

Vulnerability Factors pre-dispose individuals to develop
problems e.g psychosis

Problems are triggered by stress

If vulnerability is high, low levels of environmental stress
may trigger distress

Use and effectiveness of coping strategies goes some
way to explain why some have problems and others
don’t
A Stress &Vulnerability
Perspective Assumes

The experience of psychosis is
understandable.

Problems associated with the effects of
stigma, social exclusion and poverty are of
equal importance.

We take a collaborative approach to
assessing, planning, formulating and
delivering care.
A Stress &Vulnerability
perspective assumes

Each person is an expert in their own care.

Psychosis is on a continuum with other
human experiences.

Psychosis can be an enriching, as well as a
frightening/confusing experience.

The person over time, can make a recovery,
in terms of what that actually means to them
Stress Vulnerability Model
Zubin, J. and Spring, B. (1977) Vulnerability. A New View on Schizophrenia.
Journal of Abnormal Psychology 86, 103-126. APA. Reprinted with
permission
The bucket
Formulation
Personal vulnerabilities
Personal protectors
Family History
Coping strategies
Disruptions in early years
Self management
Environment stressors
External factors that cause
the person increased
stress.
Environmental protectors
External sources of support.
Coping

Defined as:
The active self generation of cognitive and behavioural procedures
intended either to impact upon situation directly or to minimise
the resultant distress. (Nuechterline and Dawson 1984)
Functions of coping:
- To alter the source of stress
- To regulate the emotional response
(Lazarus et al 1985)

Coping

As part of the appraisal process in a
stressful situation we examine our coping
resources

The development of these coping
strategies is affected by a number of
factors including….....
Coping
Personality
 Psychosocial development
 Locus of Control - Is it my fault?
- Was it fate?
 Social Support - What relationships will
help me fulfil my needs for coping
 Implications for isolated groups such as
people with mental health problems and
the elderly
(Shaw 1999)

Aims of Working with Coping
Strategies

To foster feelings of self control and to
help the client manage their own
experiences and problems

To reduce distress and/or disability
Coping Styles

Detachment - Being independent from the
event, not taking anything personally, not seeing
the situation as a threat, keeping things into
proportion

Rational Coping - looking for a reasonable
response, using past experience to work out
how to resolve a situation, problem solving
Coping Styles

Emotional Coping- Emotions dominate, taking
frustrations out on other people, feeling
overpowered and helpless

Avoidance Coping - Ignoring or denying the
problem, hoping it will go away, thinking about
something else and talking about it as little as
possible.
Classification of Coping
Strategies







Cognitive Strategies
attention switching
attention narrowing
self-statement
Think of something
different
Read silently
Look for explanations of
what's going on





Behavioural
Strategies
increased activity
levels
increased social
activity
decreased social
activity
Talk to someone
about the stressor
Classification of Coping
Strategies

Sensory Strategies
Relaxation exercises
Meditation
Relax in bath or shower
Hum or sing to self
What is relapse prevention?

Service users, carers and MH workers
identify each individuals early warning
sings of relapse (relapse signature)

Agree and record in advance the nature of
and timing of interventions if the signs
return (relapse drill).
Benefits of Relapse Prevention

Collaborative process were service users are viewed as
the experts of their experience.

Acknowledges personal strategies, skills and resources
for self management.

Enables relapse to be predicted and interventions put in
place to prevent or minimise negative impact on the
individual.

Evidence based.
Stages of Relapse Prevention

Psycho-education
 Two
way process where the service user and
practitioner work together to understand the
individual nature of the persons experience.
 Can
involve the use of Stress Vulnerability
Model to facilitate the process.
Stages of Relapse Prevention

Identification of Early Warning Signs (prodromal
symptoms)

Highly diverse and vary from person to person.

General examples




Anxiety
Agitation
Mistrust
Specific behavioural patterns (idiosyncratic)


Eccentric clothing
Flamboyant hair styles
Identifying Early Warning Signs

Card sorting exercise
 Client
identifies early warning signs using cards
 Arranges into early, middle, late and constant
 Review
information from both exercises with close
family/ friends to identify gaps that service user finds
difficult to remember.
Limitations
 Tendency to overlook EWS which are individual to
that person.
 Formulated in the MH workers language
Identifying Early Warning Signs

Timeline
A
detailed account of the persons narrative of the
events and experiences leading up to previous
relapse.
 Also
identifies factors that have an impact on the
onset of relapse eg external and internal stressors.

What might be the limitations/challenges
of this approach?
Monitoring

Direct- Presence or absence of EWS are
scored by the service user.

Indirect- Changes in circumstances,
stressful life events or reoccurrence of
circumstances which led to previous
relapse.
Stages of Relapse Prevention

The development of a relapse drill

A 3 stage action plan developed collaboratively and
focuses on client strengths, family and service resources

at each stage the relapse drill should consider 3 areas
for intervention



Pathway to support.
Service interventions.
Personal coping strategies.
Relapse Signature
Relapse Drill
1.
Feel worried about what
1.
Talk to John and Gemma
Cathy next door thinks of
about how I am feeling
me
2.
Challenge my thoughts
2.
Cant get to sleep at night
about Cathy
3.
Loose my temper with John 3. Watch TV to talk my mind of
my worries
4.
Stay inside and don’t see
Cathy
4.
Have a bath and listen to
music
5.
Here my mums voice talking
about how nobody likes me 5. Talk to Gemma about
medication options.
6.
Cut my arms to punish
myself for being a horrid
6.
Consider going into hospital
person.
Emergency Contact Details
Challenges to Relapse Prevention

The service user may not agree with the perceptions of
carers or MH workers.

Some people cope with MH problem by “sealing over”
and are therefore unlikely to want to consider past
experiences and the possibility of future relapse.

Many people experience difficulty with structuring their
own reality (lack of insight) leading up to relapse.

Feelings of guilt in the service user if relapse still occurs.
Using the Stress Vulnerability
Model to Assess and Plan Care

Use the case study to complete the SVM
formulation.

Is their any other information you would
need to assess this person.

How would you use this information to
plan care.
References




Lazarus, R.S. & Folkman, S. (1984). Stress, Appraisal
and coping. New York: Springer.
Nuechterlein, K. and Dawson, M. E. (1984) A Heuristic
Vulnerability-Stress model of Schizophrenia
Schizophrenia Bulletin, 10,300-12
Shaw, C. (1999) A framework from the study of coping
illness behaviour and outcomes. Journal of Advanced
Nursing 295 1246-1255
Zubin, J. and Spring, B. (1977) Vulnerability. A New
View on Schizophrenia. Journal of Abnormal Psychology
86, 103-126.