First-episode psychosis: a therapist's manual

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, which reaches out to the young person rather than waiting for them to come (section 32), 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. Sessions last 45 to 50 minutes, sometimes less at the start. The programme includes at least one joint session with the family, session 13, and a meeting with a relative at session 5 if the young person agrees; the recommended family intervention, of at least ten sessions, is offered in parallel (section 35). Some sessions can take place outside the office when useful (section 15).

Targeted mechanism. Making the episode understandable without fixing a prognosis, reducing modifiable relapse factors, establishing early recognition of the signs that herald a relapse and a plan for responding to them (section 40), reducing the distress linked to persistent experiences, preventing and treating post-psychotic depression, the depression that often follows the episode (section 26), limiting self-stigma, that is, turning prejudices about mental illness against oneself (section 26), 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

The cycle in session 9 is the sequence that maintains a distressing experience, described in section 5; the safety plan in session 11 is defined in section 9; the vocational team in session 12 supports the return to education and employment (section 36).

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's 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

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? The psychiatrist, the care coordinator, that is, the clinician who follows the young person closely and coordinates their care, the family, the vocational support worker, who supports the return to education and employment, and the general practitioner each have their own role. Section 10.

4. Is the person a minor? If so, consent, the parents' role and liaison with school are settled before you begin. 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, made up of attenuated or brief psychotic symptoms without a confirmed psychotic episode (section 7), which have their own approach.

Established schizophrenia, after several episodes, which has its own manual, Schizophrenia: cognitive therapy and recovery — a therapist's manual. Likewise, when the course leads the psychiatrist to diagnose schizoaffective disorder, Schizoaffective disorder: psychoeducation, relapse prevention and cognitive therapy — a therapist's manual takes over, with a prevention plan that brings together the early signs of mood episodes and those of psychosis.

Postpartum psychosis, which is a psychiatric emergency, and psychoses of medical origin.

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, that is, a period of changes that herald the episode, lasts 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 incidence 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-induced psychotic disorder, which fades when use stops, or which develops into 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

You say what happened, described as an episode and not as a diagnosis, in words the young person understands. You say 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. You also say 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, such as a voice or a sense of being targeted, receives a threatening interpretation: "they're out to get me", "the voice is powerful". This interpretation produces an emotion, fear, anger or shame, which drives behaviours: avoiding, hiding, obeying, watching, withdrawing. These behaviours, known as safety behaviours, protect in the moment but prevent the person from checking that the threat does not come true, and they increase isolation and stress, which feeds the next experience. The sequence thus goes round in a cycle, and it is this cycle that session 9 draws with the young person. 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.

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