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

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 mainte-

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

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'

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 solv-

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* 

nance of the delusions [18].

28 Psychosis - Biopsychosocial and Relational Perspectives

and males' coping behaviors [15, 43].

ing [16, 44].

behavioral, physical, social, or medical components.

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 important in the maintenance of psychosis.

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 significantly predicted their expressed emotion [53].

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 on how the family member may have been feeling, suggesting that they were able to recognize and describe the person's emotional state), a broad range of coping strategies to reduce distress (e.g., asking for help from someone, using humor, taking time out away from stressful situations, distraction by carrying on with work and their normal routine), and realistic optimism for the future (they believe that illness would always be part of their family member's life, but they can modify their expectations from life) [54]. Another study suggested that coping through seeking emotional support, the use of religion/spirituality, active coping, acceptance, and positive reframing were associated with less distress, while coping through self-blame was associated with higher distress scores [55].

According to CBT, hallucinations are accepted to be very similar to the symptoms of OCD. On the contrary of OCD, in hallucinations, the thoughts, images, and ideas are not attributed to the people's own mind and are attributed to the external sources. The themes are similar: violence, control, religion, and sexuality. Therefore, the strategies used for anxiety disorders are also suggested for targeting hallucinations: distraction, focusing, and anxiety reduction [39]. **Distraction** aims at helping patients to shift their attention to another stimulus or activity while hearing voices, in order to diminish the effect of hallucinations on the patients. It

From Vulnerability to Resilience: A Coping Related Approach to Psychosis

http://dx.doi.org/10.5772/intechopen.78385

31

**Focusing** aims to reduce the frequency of voices and distress by means of close monitoring of experiences, listening carefully, and leading the patient toward a change in their awareness of hallucinatory experience. Unlike the attention distraction technique, the focusing technique necessitates patients to focus more on the source, nature, and content of voices for the patients to realize that the voices are not coming from the environment and can be controlled. Patients are encouraged to perform other strategies, such as arguing with or limiting the voices and

**Anxiety reduction** is used in strategies like systematic desensitization. For example, in the imaginal exposure, a hierarchical list of symptoms and distress is constituted, and the patient is suggested to think only about the symptoms' content for a while. Then, he recognizes that

There is some evidence that the contents of delusions reflect concerns about individual's himself and how others evaluate him. The delusions can be understood in terms of cognitive biases processing the normal beliefs. There may be extreme cognitive biases underlying extreme beliefs. Psychotic patients are seemed to miscalculate the probability of an event that may occur. In fact, they are most likely to use less information to make decisions; in other words, they jump into the conclusions. Delusions could be accepted as a response to the individual's search for meaning within his personal world [65]. To assign and understand the delusions, it is important to formulate how strongly the belief is held, the context of delusions in a person's life, how understandable the belief is, and how much the person relates the

Psychotic patients catastrophically perceive the psychotic symptoms. Diagnosis or stigmatization of the others may create a traumatic effect. Thus, it is important to use a normalizing rationale and change this desperate point of view. This rationale enables the patient to apprehend that everyone has a potential to develop psychosis. Stress-vulnerability model is helpful to offer a personalized view to the patient including biological, psychological, and social explanations of how he developed vulnerable features and which stressful events triggered

Cognitive therapy suggests that the events do not directly determine our feelings and behaviors; our perceptions and interpretations influence how we feel and behave. All of us have some cognitive biases which also include some typical thinking errors. Dichotomous thinking

includes some strategies such as using headphone music and attentional focusing.

the anxiety level decreases if he focuses on the symptoms [1, 26, 64].

*2.3.2. Learning to change irrational thinking for challenging psychosis*

changing the voice tones to funny tones.

experience to himself/herself [39].

his vulnerable potential to develop psychosis [65].

The information level of relatives about psychosis determined their cognitive view to the illness. These two factors were found to be related to stress level, expressed emotion, and patients' symptom severity. Beliefs about symptoms that "the major attributes of illness representation are oriented around" are one of the important factors of Leventhal's illness perception model by which to understand the process and outcome of distress in the relatives of patients with schizophrenia [56]. The other factors are chronicity or recurrence of the condition (time line and cyclical time line), consequences, personal control, treatment control, illness coherence, causes of the condition, and patients' emotional response to their condition [57, 58].

### **2.3. Challenging psychosis: developing and enhancing adaptive strategies**

In order to establish a balance between vulnerability and resilience, we are able to help the patient to manage his symptoms by means of enhanced medical and psychological treatments. Enhanced coping strategies enable the patient to adaptively cope with distress and to reduce anxiety and stress level. This process can help reducing the severity of hallucinations and delusions. Patients can learn to modify their own coping strategies, or to use adaptive ones. Therefore, the first part includes adaptive-coping strategies used in the treatment of psychosis.

The patients may understand and try to improve their symptomatology with the help of cognitive conceptualization. Irrational thinking and maladaptive schemas should be handled with a collaborative approach. Stress-vulnerability logic may also be helpful to educate the patient about this conceptualization. In the second part described subsequently, these strategies are summarized.

Social support is also an important factor for psychosis in terms of its relation with coping. In the third part, the role of social support in the development and maintenance of psychosis is considered.

#### *2.3.1. Learning to use adaptive-coping strategies for challenging psychosis*

Following the success of Beck, clinicians have developed and used individual or group-based CBT programs for psychosis [1, 16, 17, 25, 26, 34, 59–63]. These programs generally included coping strategies because patients already have their own methods to reduce the distress caused by psychotic symptoms, so they can easily learn to enhance adaptive-coping mechanisms or to develop new ones.

According to CBT, hallucinations are accepted to be very similar to the symptoms of OCD. On the contrary of OCD, in hallucinations, the thoughts, images, and ideas are not attributed to the people's own mind and are attributed to the external sources. The themes are similar: violence, control, religion, and sexuality. Therefore, the strategies used for anxiety disorders are also suggested for targeting hallucinations: distraction, focusing, and anxiety reduction [39].

**Distraction** aims at helping patients to shift their attention to another stimulus or activity while hearing voices, in order to diminish the effect of hallucinations on the patients. It includes some strategies such as using headphone music and attentional focusing.

**Focusing** aims to reduce the frequency of voices and distress by means of close monitoring of experiences, listening carefully, and leading the patient toward a change in their awareness of hallucinatory experience. Unlike the attention distraction technique, the focusing technique necessitates patients to focus more on the source, nature, and content of voices for the patients to realize that the voices are not coming from the environment and can be controlled. Patients are encouraged to perform other strategies, such as arguing with or limiting the voices and changing the voice tones to funny tones.

**Anxiety reduction** is used in strategies like systematic desensitization. For example, in the imaginal exposure, a hierarchical list of symptoms and distress is constituted, and the patient is suggested to think only about the symptoms' content for a while. Then, he recognizes that the anxiety level decreases if he focuses on the symptoms [1, 26, 64].
