*2.2.1. The psychotic patients' own coping strategies*

Three types of psychological reaction to psychosis are suggested: *denial and lack of awareness, passive acceptance of the role of patient, acceptance of psychotic illness, and compliance to the treatment*. Neither the first one nor the second are functional because they both inhibit the treatment. The person who does not have awareness refuses the help because he/she does not believe that he/she has an illness and may gradually become more disorganized and dangerous to himself/herself and others. The second one, who passively accepts the sick role, probably abandons to try and ever loses his/her self-esteem. He/she can also develop other clinical problems, depression, and suicidal ideas. Inversely, the last one believes that he/she can learn to cope with his/her symptoms, takes medication, and is motivated to psychotherapy and can adopt the sick role when necessary [1].

According to patients' description of coping strategies with auditory hallucinations, three phases were described: startling phase in which the patients felt fear, anxiety, and desire to escape in the beginning, then investigated the meaning of voices, and do not try to escape anymore; organization phase in which many patients try to communicate with the voices; and the stabilization phase in which they start to accept the voices as part of themselves [40].

Researches about coping and psychosis show that patients generally use maladaptive-coping strategies, for example, excessive avoidance and safety behavior [41, 42]. Patients with delusions, especially persecutory delusions, often use safety behaviors to decrease the risk of danger. For this reason, they can use a number of rituals such as making hand movement or praying to avoid the effect of evil spirits or lock themselves in the house and hide under the bed to escape from the Mafia. These safety behaviors play an important role in the maintenance of the delusions [18].

*threatened*, *relationships, self-concept*—feeling ugly, *loneliness, sexual*—decrease in desire) of auditory hallucinations. They also suggested that many of the patients that they investigated believed the voices that they heard had both adaptive and maladaptive functions;

From Vulnerability to Resilience: A Coping Related Approach to Psychosis

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A more recent study which aimed to determine the effect of the patients' own coping strategies on psychotic symptoms suggested that *distractive coping technique* including relaxation, watching TV, conversation with others, listening to music, listening to the radio, body movement, hobbies, and thinking of other things were evaluated as passive-coping technique and the *counteraction strategies* including echoing voices, retorting or dissuading the voices, falling asleep, posture change, and making noises were active-coping strategies. They found that the patients did not prefer using distraction-coping strategies against hallucinations with delu-

Nelson and colleagues [50] examined the effect of earplugs use, subvocal counting (like 1,2,3… 1,2,3), and listening to music through a portable cassette on persistent auditory hallucination. They found that the most effective technique was subvocal counting; following this method, the patients mostly used earplugs and listening to music, respectively. The effect of these

Ozcan and colleagues [51] investigated the coping behaviors of patients with schizophrenia and they found that most of the patients were using at least one method. The methods can be categorized as religious activities (85%), cognitive controlling (20%), changing the dose of neuroleptic drug or changing the drug itself (20%), enhancing social activities (18%), symptomatic behaviors (10%) and listening to radio, watching TV, walking around, and drug abuse

The relatives' coping strategies with psychosis are directly related to "expressed emotion." Expressed emotion is a resistant multidimensional measure of family emotional atmospheric, through which relatives exhibit critical, hostile, and emotionally overinvolved attitudes toward a family member with mental illness [52]. Expressed emotion of relatives is especially

There are few studies in this field, but these studies usually emphasize the relation between perceived stress, coping, and expressed emotion. A recent study showed that the relatives of inpatients with first episode psychosis experienced high levels of perceived stress, poor social support, and expressed emotion in moderate to severe levels. The relatives' perceived stress

In a study that aimed to analyze the mechanisms underlying the low expressed emotion of psychotic patients' relatives, four core themes were revealed: witnessing the distress (they spent time worrying about whether their family member would commit suicide or do something to harm themselves), empathy through acceptance and understanding (they viewed the psychosis as something that could not be prevented, they tried to understand the cause, normalized the illness, and had some idea of what was important in recovery, commented

however, they would prefer not to hear voices [16, 48].

methods especially was shifting attention and reducing anxiety [50].

sional features [49].

(tea, smoking, alcohol).

*2.2.2. The coping strategies of patient's relatives*

important in the maintenance of psychosis.

significantly predicted their expressed emotion [53].

Some studies indicate that the patients' own method to cope with psychotic symptoms include both adaptive and maladaptive strategies. These strategies usually have cognitive, behavioral, physical, social, or medical components.

The results of the investigation of Falloon and Talbot [43] revealed three group strategies used to cope with auditory hallucinations: **behavior change** (e.g., speaking with people), **efforts to lower psychological arousal** (e.g., relaxation, listening to music to reduce symptoms), and **cognitive-coping methods** (e.g., listening attentively to the voices, accepting their guidance to reduce the distress, or ignoring them). They did not find any differences between females' and males' coping behaviors [15, 43].

Carr [44] assessed 200 patients and grouped 310 responses like Falloon and Talbot's study [43]. Five coping subgroups were determined. Eighty-three percent of patients used **behavior control**, 38% of them used as these coping behaviors for delusions, and 43% for hallucinations. Behavior control included *distraction involving passive diversion* such as listening to music, watching TV, or *active diversion* like writing, reading, playing a musical instrument. Using an auditory input through headphones was also found to be effective to cope with hallucinations [45]. Other types of behavior control were *physical change* involving body movement (passively; e.g., relaxation or actively; e.g., walking, swimming), *indulgence* (e.g., eating, drinking, and smoking), and *nonspecific strategies* ("I will try to do something different"). The second important subgroup was **socialization** via talking to family or friends, but social withdrawal and avoidance were also reported. Tarrier has also found and reported that these avoidant behaviors were used as a conscious-coping method [46]. **Cognitive control** was the third one, and it has its own three subgroups including *suppression of unwanted thoughts and perceptions* (I ignore the delusions, I try not to think about the voices), *shifted attention* (redirecting the attention to the neutral ideas), and *problem solving*. **Medical care** (using/changing medication, going to hospital, visiting a mental health specialist) and **symptomatic behaviors** (telling the voices to stop talking, shouting them to leave him/her alone, behaving aggressively) as the remaining subgroups were the rarely used coping strategies. The patients with delusion did not prefer passive coping strategies; they preferred to use active ones, such as problem solving [16, 44].

Cohen and Berk [47] evaluated the coping styles of 86 patients to determine which strategies were used for which symptoms. They found that patients used "*fighting back*" and *"medical strategies"* to cope with psychotic symptoms and "*prayer*" for schizophrenic thoughts [47].

Miller and colleagues [48] stated that 52% of patients that they interviewed reported positive effect (*relaxing, companionship, financial*—for example, income—*protective, self-concept*—for example, feeling attractive—*reactions of others*—for example, people are nicer *performance—*the need to hear voices to maintain self-care, *relationships*—the need to hear voices to be close to people, *sexual*—increase in desire), whereas 94% of them commented adverse effect (*financial*—incapacity to work, *emotional distress, performance*—impairment in functioning, *reactions of others*—for example, the stigmatization, *feeling endangered or*  *threatened*, *relationships, self-concept*—feeling ugly, *loneliness, sexual*—decrease in desire) of auditory hallucinations. They also suggested that many of the patients that they investigated believed the voices that they heard had both adaptive and maladaptive functions; however, they would prefer not to hear voices [16, 48].

A more recent study which aimed to determine the effect of the patients' own coping strategies on psychotic symptoms suggested that *distractive coping technique* including relaxation, watching TV, conversation with others, listening to music, listening to the radio, body movement, hobbies, and thinking of other things were evaluated as passive-coping technique and the *counteraction strategies* including echoing voices, retorting or dissuading the voices, falling asleep, posture change, and making noises were active-coping strategies. They found that the patients did not prefer using distraction-coping strategies against hallucinations with delusional features [49].

Nelson and colleagues [50] examined the effect of earplugs use, subvocal counting (like 1,2,3… 1,2,3), and listening to music through a portable cassette on persistent auditory hallucination. They found that the most effective technique was subvocal counting; following this method, the patients mostly used earplugs and listening to music, respectively. The effect of these methods especially was shifting attention and reducing anxiety [50].

Ozcan and colleagues [51] investigated the coping behaviors of patients with schizophrenia and they found that most of the patients were using at least one method. The methods can be categorized as religious activities (85%), cognitive controlling (20%), changing the dose of neuroleptic drug or changing the drug itself (20%), enhancing social activities (18%), symptomatic behaviors (10%) and listening to radio, watching TV, walking around, and drug abuse (tea, smoking, alcohol).
