This programme is a treatment manual for mental health professionals. It assumes clinical training, experience with psychotic disorders, work within a team or in close liaison with a psychiatrist, and a supervision framework. It replaces neither your clinical judgement nor your professional responsibility. Diagnostic criteria are reworded here in our own words, never reproduced. Two warnings specific to this indication. An acute psychotic episode calls for psychiatric assessment and immediate medical care; this programme begins once the acute phase is contained. And suicide risk is high in the first years, particularly in the months after the episode; it is asked about at every session, section 9.
1. The programme at a glance
Indication. Adolescents over fifteen or young adults, within two to three years of a first episode of psychosis, whatever the provisional diagnosis, followed by a psychiatrist, ideally in an early intervention team.
Reference model. The psychological part of early intervention programmes: active engagement, psychoeducation based on a stress-vulnerability model, cognitive behavioural therapy for psychosis adapted to young people, work on relapse prevention and early warning signs, family intervention, and support for returning to education and employment, in coordination with the rest of the team.
Format. Sixteen key sessions over twelve to eighteen months, weekly at first then spaced out, within early intervention care that usually lasts two to three years. 45- to 50-minute sessions, sometimes shorter at the start. At least two sessions with the family. Sessions outside the office when useful.
Targeted mechanism. Making the episode understandable without fixing a prognosis, reducing modifiable relapse factors, establishing early recognition of warning signs and a plan, reducing the distress linked to persistent experiences, preventing and treating post-psychotic depression, limiting self-stigma, and maintaining or restoring social, educational and occupational functioning.
| Phase |
Session |
Topic |
Session output |
| I. Engaging |
1 |
Meeting after the storm |
Connection made, immediate danger assessed |
|
2 |
Putting words to what happened |
Account of the episode in the young person's words |
|
3 |
Assessment |
Risks, substances, trauma and health assessed |
| II. Understanding |
4 |
Stress and vulnerability |
Model explained, linked to their story |
|
5 |
What came before the episode |
First signs identified |
|
6 |
Treatment, through shared decision-making |
Questions and fears gathered |
| III. Getting going again |
7 |
Getting back into a rhythm |
Sleep and day structured |
|
8 |
Cannabis and other substances |
Goal chosen by the young person |
|
9 |
Experiences that persist |
Cycle of a distressing experience, strategies tried |
|
10 |
Mid-point review |
Measures repeated, plan revised |
| IV. Getting back on one's feet |
11 |
After the episode: mood, shame, label |
Written safety plan, self-stigma addressed |
|
12 |
Studies and work |
A concrete step with the vocational team |
|
13 |
The family |
Joint session, written agreement |
| V. Consolidating |
14 |
My prevention plan |
Early signs and plan written and shared |
|
15 |
What the episode does not say about me |
Projects and identity linked |
|
16 |
Review and next steps |
Measures repeated, handover organised |
What the person takes away. Seven printable worksheets, listed in section 42: what happened, my first signs, my day and my sleep, cannabis and other substances, when it is still hard, the corner for family and friends, my prevention plan.
What sets this programme apart from the other manuals on this site. Three things. A young patient, for whom most of adult life is still to be built. A team-based service of which the psychologist is only one part. And an uncertainty to hold: no one yet knows what this episode will become, and it is up to the clinician not to decide too soon.
2. Before you begin
Who this programme is for
For psychologists, psychiatrists, nurses and psychotherapists trained in cognitive behavioural therapy who work with young people after a first episode of psychosis, within a team or in close liaison with a psychiatrist. It is not intended for patients or their families.
When to start
Not at the height of the episode. A young person who is very disorganised, very agitated or overwhelmed by voices cannot do this work. Contact, however, can begin: a regular, brief, reassuring presence, during the hospital stay or in the first weeks.
As soon as the acute phase is contained. The first weeks after the episode are often when the person has the most questions, and when the alliance is at stake.
The five preliminary decisions
1. Has immediate danger been ruled out? For the person and for others. Section 9.
2. Has a medical work-up been done? A first episode calls for an examination, blood tests, drug screening and, depending on the picture, imaging or other investigations. Section 7.
3. Who is in the team, and who does what? Psychiatrist, care coordinator, family, vocational support, general practitioner. Section 10.
4. Is the person a minor? Consent, the parents' role, school. Section 38.
5. What role for the family? The family is almost always involved; the young person's agreement is sought and renegotiated. Section 35.
What this programme does not treat
The acute episode itself, which calls for immediate psychiatric care.
At-risk mental states, without a confirmed psychotic episode, which have their own approach.
Established schizophrenia, after several episodes, which has its own manual.
Postpartum psychosis, which is a psychiatric emergency, and psychoses of medical origin.
What this programme is not
It is not a programme for disclosing schizophrenia. It is not a monitoring programme. And it is not work that waits for symptoms to disappear before taking an interest in life: studies, friends, work and housing are part of treatment from the start.
How to use it
First read sections 3 to 15, then sections 32, 33 and 35 before the first session: engagement, psychotic experiences and the family come into play from the first meeting. The sessions described are key sessions; some take up several. Section 43 says what must not be let go.
3. The clinical picture
What a psychotic episode is
A period in which the person loses contact with shared reality: delusions, hallucinations, disorganised thinking and speech, disorganised or catatonic behaviour, in very varied degrees and combinations. We speak of a first episode when these symptoms reach, for the first time, an intensity and duration that justify care.
What often comes before
A prodromal phase of weeks to months, sometimes longer: withdrawal, falling grades, disrupted sleep, irritability, anxiety, low mood, mistrust, a sense that the world has changed, odd ideas, unusual preoccupations. It is often mistaken for adolescent turmoil, depression or substance use, or goes unnoticed.
What young people describe
A world that has become strange, charged with meaning, threatening. Messages in songs, looks, screens. Voices that comment or give orders. Thoughts that race, empty out or get muddled. And afterwards: the shock of hospital, sometimes compulsion, shame about what they said or did, fear that it will happen again, tiredness from the medication, and the question that keeps coming back: am I mad, is my life over?
What you see in the consulting room
Depending on the moment: a person who is still mistrustful or slowed down, who says little; a person who minimises everything in order to move on; a person who is devastated, sad, ashamed. Often great sensitivity to how they are looked at. Sometimes vocabulary borrowed from social media or from the beliefs of their community to describe what happened.
Epidemiology
First episodes most often occur between late adolescence and the mid-thirties, somewhat earlier in men. Their frequency varies by place and population: it is higher in urban areas, in some migrant and minority populations, and among daily users of high-potency cannabis.
Duration of untreated psychosis
The delay between the onset of psychotic symptoms and the first adequate treatment is often several months, sometimes more than a year. A longer duration is associated with a poorer course in reviews of cohort studies, which justifies early detection and rapid access to care.
4. Possible trajectories
Why this section exists
Because the question "what's wrong with me?" comes early, and the honest answer is often: we don't know yet.
What a first episode can become
A single episode, followed by lasting remission, in some people.
Recurrent episodes, with periods of remission between them.
A more continuous course, with persistent symptoms and an impact on functioning, in others.
A mood disorder with psychotic features — bipolar disorder, psychotic depression — revealed over time.
A substance-related disorder, which fades when use stops, or which reveals a lasting psychotic disorder.
What we know about the course
Cohort data show great heterogeneity. A majority of people achieve symptomatic remission after a treated first episode. The risk of relapse in the following five years, however, is high, and it rises sharply when treatment is stopped. Functional recovery — studies, work, relationships — is slower and less frequent than symptomatic remission, which justifies attending to it from the start.
What you say
What happened, using the words of the episode. What we know: that many people do well afterwards, that relapses are common but not inevitable, and that some of what makes them more likely can be acted on. What we do not know yet. And that a diagnosis, if one is to be made, will be made by the psychiatrist, over time.
5. The model
The model that guides this programme is presented to the young person in plain language, with their words and examples. It does not say why the episode happened; it says what makes episodes more or less likely, and what can be done.
Stress and vulnerability
Everyone has a greater or lesser vulnerability to this kind of experience, linked to genetic and developmental factors and to their history. Stressors — lack of sleep, cannabis and other substances, intense stress, isolation, trauma, pressure at school or at home — add to it. When their sum exceeds a threshold, an episode can occur. You do not choose your vulnerability; you can act on some of the stressors, and on what protects.
Experiences on a continuum
Many people have unusual experiences at some point: hearing their name when no one has said it, sensing a presence, feeling that an event is meant for them. These experiences become a problem when they are frequent, intrusive, interpreted as threatening, and when they lead to distress and costly behaviours.
What maintains distressing experiences
A troubling experience — a voice, a sense of being targeted — receives a threatening interpretation — "they're out to get me", "the voice is powerful" — which produces an emotion — fear, anger, shame — which drives behaviours — avoiding, hiding, obeying, watching, withdrawing — which prevent checking and increase isolation and stress. Lack of sleep, worry and cannabis feed every link.
Recovery
Recovery is not just the disappearance of symptoms: it means regaining a life one judges satisfying, projects, relationships, an identity that is not reduced to the episode. It can begin before symptoms end.
What the model explains to the young person
That what happened to them is a human experience, which happens to others, and which can be treated. That it is not their fault, and not a flaw of character. That some things make another episode more likely, and that they can act on several of them. And that an episode does not decide the rest of their life.