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

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

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].

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

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 strate-

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

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 mecha-

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

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

self-blame was associated with higher distress scores [55].

30 Psychosis - Biopsychosocial and Relational Perspectives

psychosis.

considered.

gies are summarized.

nisms or to develop new ones.

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 experience to himself/herself [39].

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 his vulnerable potential to develop psychosis [65].

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 (black or white), arbitrary inference (jumping to conclusions), and selective abstraction (only focusing a little part of the overall picture) are some of the most observed thinking errors in psychosis. With the help of cognitive model, patient can understand that how he interprets the situations can affect how he feels and how he reacts that way. He also comprehends the relation between his irrational thinking and his symptomatology. Then, the patient and the therapist can collaboratively work on changing the interpretations of the problem and exploring more rational perceptions and more adaptive alternative responses [65].

*2.3.3.2. The role of social support in the maintenance and recovery of psychosis*

emotion, and accordingly to positively affect the treatment process [72].

*2.3.3.3. Integrating family members to cognitive-behavioral interventions for challenging* 

individual to the use of adaptive-coping strategies [72].

improving interpersonal functioning [75].

via cognitive-behavioral therapy.

port network [73].

*psychosis*

**3. Conclusion**

Poor social networks may also cause more vulnerability during acute episode; therefore, psychotic symptoms can get worse and patients can continue withdrawals [69, 71]. Lack of positive social support was associated to higher levels of stress and psychopathology [68]. On the other hand, positive social support was clearly seen as a factor which motivated the

From Vulnerability to Resilience: A Coping Related Approach to Psychosis

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

33

Most patients often receive support from close family, as compared to friends and other relatives. In addition, schizophrenic patients find it particularly difficult to find emotional support [73], but reported the need for more emotional support, advice, and trust-based relationships [74]. Some researchers tried to quantitatively and functionally complement the patients' sup-

The results of the studies of social support indicate that both family and peer-based social support interventions can be used clinically to improve social support, to decrease the expressed

There is substantial evidence that integrating family members to psychotic patient's treatment is very helpful to reduce relapses. Techniques used in family interventions often tend to be on CBT based. They usually focus on reducing high expressed emotion and improving interpersonal environment. The key elements of these interventions are assessment and problem formulation; psychoeducation about the nature of the illness, its prognosis and treatment; and problem-solving techniques aiming to reduce conflicts and concerns, setting goals and

The aim of this chapter was to understand the continuum between the normality and psychosis, to review the coping-related explanations and coping strategies for psychosis. It is important to understand patients' own coping mechanisms, as well as their relatives' coping strategies because of the relation between psychotic symptoms, "expressed emotion," and "social support." Studies show that most of these coping strategies used are maladaptive, thus it is important to educate patients about cognitive model and adaptive-coping strategies

It is remarkable that almost all cognitive explanations have a similarity with vulnerabilitystress model, and they resemble each other except a few differences. The author tries to summarize all these explanations herein subsequently and show in a schematic assumption

When a person with cognitive and physical vulnerability is exposed to stressful life events (e.g., low social support, environmental difficulties, or psychological traumas) which surpass his vulnerability limit, he may experience an anomalous experience. For example, he can hear a whisper

named as "a Coping Related Model for Psychosis" in **Figure 1**.

There is also a link between early psycho-social stressors, dysfunctional assumptions underlying core maladaptive schemas, and the psychotic symptoms. Fowler and colleagues [1] summarized the main schematic themes for psychosis, and they categorized five schemas including *the belief that the self is extremely vulnerable to harm*—for example, "I am unsafe," *the belief that one is highly vulnerable to losing self-control*—for example, "I am dangerous to others," *the belief that the self is doomed to social isolation* "I am totally alone in the world," *the belief in inner defectiveness*—for example, "I am damaged/deficient," *the belief in strict standards*—for example, "I must perform the optimum standard in all areas at all times (schema compensation). Other core maladaptive schemas such as "I am different," "I am special," and "I am abandoned" are also effective in the development and the maintenance of the psychotic symptoms, especially of the delusions [65].

### *2.3.3. The role of social support for challenging psychosis*

It is known that individuals with psychosis have smaller social networks and less satisfying relationships [66]. Social support is accepted as an important factor in every stage: in the development, maintenance, and recovery of psychosis.

#### *2.3.3.1. The role of social support in the development of psychosis*

Outcomes of the studies which examined the relation of positive social support/lack of social support and psychosis indicated many important results.

One of these studies in which the quantity and quality of social relationships in young adults at ultra-high-risk for psychosis were evaluated, fewer close friends, less diverse social networks, less perceived social support, poorer relationship quality with family and friends, and more loneliness were determined, and these features have been found to be related to low functioning, and also a high symptom severity [66]. Correlatively, Schuldberg and colleagues have found that high-risk individuals reported receiving significantly less positive social support from both friends and family [67]. The relationship between psychosis proneness and negative social support (e.g., hostility and criticism from others) has not been examined yet [68].

In a study that aimed to understand the gender differences between childhood physical and sexual abuse, social support and psychosis, it was suggested that especially for women with a child maltreatment history, powerful social network systems and perceptions of social support were found as important factors for resilience and against developing psychosis [69].

A study that examined the role of social support in delays between the onset of psychotic illness and initiation of an adequate treatment found that good social support was associated with a significant increase in this duration [70].

## *2.3.3.2. The role of social support in the maintenance and recovery of psychosis*

Poor social networks may also cause more vulnerability during acute episode; therefore, psychotic symptoms can get worse and patients can continue withdrawals [69, 71]. Lack of positive social support was associated to higher levels of stress and psychopathology [68]. On the other hand, positive social support was clearly seen as a factor which motivated the individual to the use of adaptive-coping strategies [72].

Most patients often receive support from close family, as compared to friends and other relatives. In addition, schizophrenic patients find it particularly difficult to find emotional support [73], but reported the need for more emotional support, advice, and trust-based relationships [74]. Some researchers tried to quantitatively and functionally complement the patients' support network [73].

The results of the studies of social support indicate that both family and peer-based social support interventions can be used clinically to improve social support, to decrease the expressed emotion, and accordingly to positively affect the treatment process [72].
