| Client A |
Client A presented with long-standing negative symptoms related to CHR (anhedonia, avolition), in addition to comorbid social anxiety and mild autism spectrum disorder. Client is living with their grandparents and siblings. Client and their family were seeking treatment to increase comfort with social interactions, stabilize mood, and create independence from grandparents. Prior to the COVID-19 outbreak, treatment was focusing on behavioral activation (especially encouraging time out of the home), exposure to face-to-face social interaction, and cognitive restructuring of maladaptive thought patterns related to social engagement. |
| Clinical concern |
Example solution/intervention [relevant module(s)]*
|
| Adjusting to a telepsychotherapy session when client experiences negative symptoms that impact social interactions (flat affect, delayed response time), and may potentially disrupt rapport or therapeutic engagement |
Adapt therapy session length and frequency to optimize engagement and minimize client discomfort by scheduling shorter, but more frequent sessions (moving from one 50-minute session a week, to two 20-minute sessions) [Module: Engagement] Use screen sharing function on telehealth platforms to allow a mutual focus on a document/activity in order to increase comfort by minimizing spotlight on face-to-face conversation [Modules: Coping; Engagement] Brainstorm preferred methods of “checking-in” during session to ensure the Client is present and focused on discussion [Modules: Engagement; Problem Solving] Use the non-optimal communication conditions as an opportunity for in-vivo exposure to potentially challenging social interaction [Module: CBT-CHR - Exposure] |
| Maintaining behavioral activation exercises during a “stay-at-home” order |
Transition focus of behavioral activation exercises to highlight those preferred by the Client, but still accessible within the home (i.e., rearranging furniture within bedroom, writing in a journal, completing a puzzle, online interaction). [Modules: Collaborative Goal Setting; Problem Solving] Encourage safe, physically isolated outdoor activities (e.g., short walk while listening to music) [Modules: Coping; CBT-CHR – Activity Scheduling] Check in throughout the week (text message, quick call) to encourage completion of activities [Module: Engagement] |
| Transition in family dynamics that may occur when regular schedules are disrupted, and all family members are home due to a “stay-at-home” order |
Establish routines for learning, work, meals and family time [Modules: Family Therapy; Problem Solving] Collaborate around a family plan for use of technology [Modules: Family Therapy; Problem Solving] |
Experiencing increased mood lability and the recurrence of urges to engage in nonsuicidal self-injury
|
Incorporate more Dialectical-Behavioral Therapy (DBT) strategies and skills (e.g., chain analysis; distress tolerance skills) [Module: Comorbid Treatment] Use videoconference screen sharing to jointly review DBT worksheets [Modules: Coping; Engagement] Plan pleasant activities and physical activities that can be completed from home (e.g., joining an online fitness class) [Modules: Coping; CBT-CHR – Activity Scheduling] Revise safety plan with client and family to add more virtual resources and other potential adult supports. Continue to reinforce protective factors [Module: Safety Planning] |
| Client B |
Client B initiated treatment for positive symptoms related to CHR (hallucinations, delusions) that persisted over one year after a substance-induced attenuated psychosis experience. Client also presented with residual posttraumatic stress symptoms from childhood trauma (but did not meet full criteria for PTSD). Client is a college student who was living on campus up until the COVID-19 outbreak when they had to move back home with parents and siblings. Treatment focused on helping client to better understand the impact of their childhood trauma on current relationships and substance use, including psychoeducation about trauma and CHR, and coping strategies from Trauma Focused-CBT (TF-CBT) and Cognitive Processing Therapy (CPT). Distress tolerance skills were also used in conjunction with CBT-CHR strategies. |
| Clinical concern |
Example solution/intervention [relevant module(s)]*
|
| Relapse of cannabis use |
Provide psychoeducation on cannabis use and associated risk of psychotic symptoms [Modules: Psychoeducation; Substance Use] Use a decisional balance exercise [Module: Substance Use] Complete functional analysis of cannabis use in the specific context of current physical isolation (i.e. is the cannabis use a way to cope with boredom, stress, sleep difficulties, etc.?) [Module: Substance Use] |
| Adjusting to online courses |
Clarify class schedule, shifting expectations, availability of professors and TA virtual office hours [Modules: Coping; School/Occupation Support; Problem Solving] Role-play methods of asking for support from faculty and visualizing the process. [Modules: Social Skills; Problem Solving] |
| Adapting to “stay-at-home” order while keeping connected and active |
Brainstorm activities of interest [Module: Problem Solving] Schedule work-out time with siblings at home [Modules: Coping; Family Therapy] Revive mountain bike hobby (ordering parts, rebuilding, and going for a ride in neighborhood) [Module: Problem Solving] Schedule video-chatting with friends [Module: Coping] |
Coping with exacerbation of posttraumatic stress and CHR symptoms
|
Provide psychoeducation on exacerbation of trauma and CHR responses during times of acute stress, and continue TF-CBT and CPT work [Modules: Psychoeducation; Comorbid Treatment] Assign self-guided therapy work on the PTSD Coach app (US Department of Veterans Affairs, 2020; e.g., trauma symptom tracking; mindfulness and relaxation skills) with clinician support [Modules: Coping; Comorbid Treatment] Use videoconference screen sharing to review the posttraumatic stress symptom assessment PDF from the PTSD Coach app [Module: Assessment] Use CBT-CHR skills to evaluate beliefs and generate alternative explanations [Module: CBT-CHR] Provide more frequent, brief check-ins [Module: Engagement] |
| Client C |
Client C sought treatment for depression and positive symptoms related to CHR (hallucinations, paranoia), specifically suspiciousness of others at work. Client also met criteria for obsessive-compulsive disorder. Mutual goals for treatment were to address suspiciousness and work difficulties, become more socially active, return to previous levels of effective functioning (e.g., increasing hope, connection with others, and sleep hygiene), and better manage distressing intrusive thoughts and images of physically harming friends and family. Prior to the COVID-19 outbreak, treatment focused on CHR and OCD psychoeducation, Exposure and Response Prevention (ERP), CBT-CHR, and behavioral activation, and building social connections. |
| Clinical concern |
Example solution/intervention [relevant module(s)]*
|
| Feeling suspicious of others, including fears that their boss is plotting against them |
Build engagement and rapport, and identify thoughts, feelings, and behaviors [Module: CBT-CHR] Generate and evaluate alternative explanations [Module: CBT-CHR] |
Minimizing violent intrusive thoughts and associated distress
|
Recognize the connection between heightened stress and increased symptoms [Module: Psychoeducation; Comorbid Treatment] Use of NOCD: Effective Care for OCD app (NOCD Inc, 2020) as an adjunct to treatment for psychoeducation, mindfulness, and ERP [Modules: Assessment; Coping] Continue CBT-CHR work to target other safety behaviors and unhelpful thoughts [Module: CBT-CHR] |
Prioritizing healthy sleep behavior in the absence of a clear schedule or routine
|
Create sleep goals (agreed upon sleep schedule, routine), and use external supports (e.g. caregiver assisted morning wake-ups, internet shutdown after certain time, blue light filters for electronic screens, alarm reminders for both wake up and bedtime) as needed [Modules: Problem Solving; Wellness] Incorporate client’s choice of YouTube videos for meditation and supporting sleep hygiene [Modules: Coping; Engagement] |
| Maintaining clinical gains in regard to social activity and self-esteem during physical distancing due to COVID-19 |
Establish adjusted social goals during the pandemic [Module: Collaborative Goal Setting] Continue social engagement through alternative means (e.g., video-chatting with family and friends; joining an online gaming group; joining a writing group) [Module: Problem Solving] |
