This study has attempted to construct an understanding of LOP within a cognitive-
behavioural fiamework. This p^clplogical approach is particularly indicated for this
client group due to the succèsstul work aheacfy being conducted with younger people
with psychosis and by the occurrence of schema-level problems in people with LOP as
indicated by the findings of this study. This implies that treatment needs to go beyond
intervening with immediate thoughts, feelings and behaviours associated with LOP, and
work with the schema level.
The broad aims o f cognitive-behavioural therapy for people with psychosis are to reduce
distress caused by symptoms, to reduce emotional disturbance and to help the individual
arrive at an understanding o f psychosis (Gaiety et al 2000). This approach focuses on the
meaning of symptoms for individuals and treatment is conducted in the spirit of
collaborative empiricism. Essentially, a CBT intervention for people with LOP will be
similar to therapy with younger people with psychosis. Factors that may need to be taken
into account with an older person might include sensorial and information processing
changes that occur in old age, the issue of chronic physical illnesses, and having an
awareness o f the older person’s expectations towards therapy and the therapist (Bizzini
1998, Laidlaw 2001). However, Lajidlaw (2001) cautions against the view that therapy
for older people must always be adapted and he emphasises that possible ad^tation
should be considered on a case-by-case basis.
The CBT approach is structured and time-limited, although the duration and frequency
people whose cognitive processing has slowed may need more sessions in order to
complete treatment. Many therapists working with earfy-onset psychosis have
conceptuahsed treatment as a series o f stages (e.g. Garety et al 2000, Perris &
Skagerlind 1998). A possible stage-model for LOP is set out below. These stages often
overlap, for example engagement will be enhanced when the distress caused by
psychotic symptoms has been reduced.
Stage 1 Engagement
This phase (called the “attachment” and engagement phase by Perris & Skagerlind 1998)
msy be particularly important for LOP if the theories about attachment and separation
issues are bom out in future research. This stage is important in gaining the trust of the
person, and an assessment of their individual needs and resources can be made.
Following this initial treatment goals can be drawn-up. Often these meetings will be
shorter and more frequent than a standard CBT approach as people who are distressed
m ^ not be able to tolerate long periods of contact Gaining the confidence and trust of
people with LOP may take a long time and the pace will need to be set by them. This is
true o f most people with psychosis, and seems even more so with this group due to the
high rates o f paranoia and histories of threatening-discriminating experiences, which
promote distrust of others.
Stage 2 Reducing distress
The use o f general CBT strategies to reduce the immediate distress caused by symptoms
in this phase may also help to gain the trust of people with LOP. This phase may also
target m i^ t include anxiety related to the experience of psychosis, and here a
normahsing strategy might be useful. Further, this study suggests that for people with
LOP, low morale, lonely-dissatisfaction and a negative attitude to ageing may all be
areas to target in therapy. These may need to be addressed directly or may improve if
psychotic symptoms can be reduced,
Stage 3 Developing an understanding of LOP
This phase involves collaborating with the person to understand their experience, and
may also include a psycho-educational component where current understandings of
psychosis are shared with the client. Garety et al (2000) aims to help the chent arrive at
an understanding o f psychosis that promotes their active participation in reducing the
risk o f relapse.
Stage 4 Working on positive symptoms
After both the client and the therapist have reached an understanding of psychosis, the
challenging of disabling and distressing behefs about experiences can occur. However,
the emotional consequences o f changing strongly held beliefs need to be explored.
Further, the challenging of beliefs is conducted in a gentle manner through
coHaborative-empiricism, as direct confrontations will probabfy result in disengagement
from therapy.
Stage 5 Schema level work
The results o f this exploratory study suggest that maladaptive schemas may present in
risk o f future relapses. This woik could be carried out during the other stages or only
when die person is more stable and major delusional worries are no longer as distressing
them. The aim of this work for people with LOP would be to address the underlying
personality issues that may have contributed to the presence of LOP in the first place.
Stage 6 Building social networks
This group of people has often been identified as isolated. This study suggests that
people with LOP might be isolated because they find relationships particularly stressful
and difficult to maintain. For these individuals, any social network put in place may
need to reflect a level o f professionalism, such as d ^ centres, who may be more tolerant
and understanding of interpersonal difficulties. It may also be extremely important to
allow the person with LOP some distance from social relationships, so that as suggested
by the Corin & Lauzon (1992) study, these people can experience contact but in a rather
distant way.
Stage 7 Reducing the risk of relapse
This phase would incorporate the identification of signs o f relapse and also aim to
ensure that the person has been able to successfully implement the CBT strategies
learned during treatment.
Stage 8 De-attachment issues
It has been hypothesised in this study that people with LOP may have attachment and
therapeutic relationships has been built between client and therapist, issues around
ending treatment may be particularly pertinent for this group.