Tangible Needs and External Stressors Faced by Chinese Ameri.docx

Tangible Needs and External Stressors
Faced by Chinese American Families with
a Member Having Schizophrenia
Winnie Kung
This article examines the tangible needs and external stressors
experienced by Chinese
American families with a member living with schizophrenia, in
the context of a six-month
pilot study of family psychoeducation. Therapists’ notes from
117 family and group sessions
were analyzed. The families expressed concerns regarding
housing, finance, work, study, and
the shortage of bilingual psychosocial services. Interacting with
government offices and
social services agencies caused anxiety and frustration, partly
due to the high stakes involved
given their low socioeconomic status, and partly due to the
bureaucracy. As immigrants,
study participants had needs for language translation,
knowledge about resources, and advo-
cacy by case managers. This study also highlights the
importance of interventions beyond
the micro individual level to the mezzo and macro levels, where
changes in organizations
and policies are necessary.
KEY WORDS: caregivers; Chinese Americans; environmental
stressors; ethnic sensitivity;
schizophrenia

This study aims to address the knowledge gap in understanding
the challenges faced by Chinese American families with a
member
living with schizophrenia in relation to their tangible
needs and external stressors from the environment. I
conducted this research in the context of an interven-
tion study of family psychoeducation that I previously
developed and pilot-tested as an ethnic-sensitive pro-
gram for Chinese Americans ( Kung, Tseng, Wang,
Hsu, & Chen, 2012). Family psychoeducation has
been proven effective in reducing caregiver stress and
the relapse rate of individuals with schizophrenia
( Jewell, Downing, & McFarlane, 2009; Lefley, 2010;
McFarlane, Dixon, Lukens, & Lucksted, 2003). The
intervention protocols focus on educating the fami-
lies about the nature of the illness, promoting better
communication, and helping family members re-
solve conflicts ( Anderson, Reiss, & Hogarty, 1986;
McFarlane, 2002) to reduce “expressed emotions”
such as criticism and overinvolvement, which highly
predict relapses ( Butzlaff & Hooley, 1998; Hooley,
2007; Leff & Vaughn, 1985; Marom, Munitz, Jones,
Weizman, & Hermesh, 2005). Few studies had been
conducted with Chinese American families, many of
whom face unique challenges due to their immigrant
status and cultural values ( Kung, 2003).
To more thoroughly understand the stresses ex-
perienced by these families so as to better meet their
needs and to refine the family psychoeducation pro-
tocol, a qualitative inquiry was conducted using the
clinicians’ session notes from the intervention study.
Whereas the family psychoeducation model in its
original design focused on resolving the psycho-
logical and relational issues within the families, this
investigation noted that these families’ struggles were

closely tied to their tangible needs. These needs in-
cluded basic livelihood such as housing, employ-
ment, and finance. They were also faced with stresses
that were imposed on them from external systems.
These findings highlight the importance for human
services practitioners to use the person-in-environment
lens in understanding Chinese American families
and to intervene at various systems levels to facilitate
current relief and lasting changes.
BACKGROUND LITERATURE
Stressors for Chinese American Families
Individuals living with schizophrenia, with its de-
bilitating symptoms and a relapsing course, face enor-
mous challenges. The active symptoms affect their
cognition, emotions, behaviors, and quality of life,
leading to chronic disability requiring a lot of assistance
53doi: 10.1093/swr/svv047 © 2016 National Association of
Social Workers
( American Psychiatric Association, 2013). For many,
their families are their major source of support
( Hatfield, 1990). However, the family caregivers are
also subjected to immense stress, which affects both
their physical health and their mental health ( Awad &
Voruganti, 2008; Glanville & Dixon, 2005; Hatfield,
1990; Rose, 1996; Tessler & Gamache, 2000). These
families need resources in the community to help
them cope. In the caregiving literature, caregivers’
appraisal of available resources was found to affect
their stress level ( Zegwaard, Aartsen, Cuijpers, &
Grypdonck, 2011), which is in accord with the now
classic stress and coping model as postulated by

Lazarus and Folkman (1984).
Chinese American families with a member living
with schizophrenia experience extra burden due to
their immigrant status and cultural values. As im-
migrants, their knowledge about community re-
sources and social support may be limited, and they
have to cope with stresses related to the language bar-
rier and racial discrimination ( Sue, Cheng, Saad, &
Chu, 2012). In fact, 68% of Chinese Americans are
immigrants whose most proficient language is not
English ( U.S. Census Bureau, 2014). These realities
may further compromise their ability to negotiate
the systems.
People of Chinese descent are one of the fastest-
growing minority groups in the United States, and
are now the largest group (24%) within the Asian/
Pacific Islander population ( U.S. Census Bureau,
2014). Asians being the “model minority” with good
health and mental health and socioeconomic stabil-
ity has been proven a myth ( Sue et al., 2012). The
extreme cultural stigma ascribed to mental illness can
further alienate efforts to seek social support from
within the community ( WonPat-Borja, Yang, Link, &
Phelan, 2012) and dampen efforts to seek external
help ( Abe-Kim et al., 2007). When coupled with a
cultural obligation to care for their family members,
caregiver stress is aggravated ( Zegwaard, Aartsen,
Grypdonck, & Cuijpers, 2013). Because many Chi-
nese immigrants are of lower socioeconomic status
(SES) (15.6% live below the poverty line [ U.S. Census,
2013]), unmet tangible needs are likely to cause
enormous burden when their ability to navigate the
complex service systems is limited.

Contribution of This Qualitative Study
Although an increasing number of qualitative studies
have explored the stresses experienced by families
with a member living with serious mental illness
(SMI) (for example, Corsentino, Molinari, Gum,
Roscoe, & Mills, 2008; González-Torres, Oraa,
Arístegui, Fernández-Rivas, & Guimon, 2007), few
have included Asian Americans. Studies also tended
to address families’ internal stressors ( Zegwaard et al.,
2011) while paying little attention to their tangible
needs and external stressors. The factors highlighted
in this study could be relevant, especially for immi-
grant families with limited means. This qualitative
study addresses this knowledge gap by analyzing fam-
ily and group therapy session notes collected in an
intervention research of family psychoeducation with
Chinese Americans.
In qualitative studies on families with SMIs, ana-
lyzed data were usually based on one-time interviews
of participants who reflected on their experiences (for
example, Corsentino et al., 2008). A limitation of
these studies is that whereas they may depict partici-
pants’ most pressing issues at the time of the inter-
views, participants’ ongoing struggles are sometimes
taken for granted and omitted, even though these
challenges may affect them tremendously. A literature
review on stress experienced by families with a mem-
ber having schizophrenia noted no study based on
data collected over time during treatment.
Therapy session notes have been used in qualitative
studies to capture the major themes in treatment and
issues faced by clients (for example, Chenail, Somers, &
Benjamin, 2009; Floersch, 2000). Therapy notes may

provide a deeper ongoing understanding of clients’
struggles. Clinicians who have been treating these
individuals or families over time provide a valuable
perspective in understanding their experiences, which
complements the client perspective ( Swartz, 2006).
This report is a novel examination of stress in families
with a member living with schizophrenia.
It should be noted that although the use of the term
“patients” to describe research participants is outdated,
except in clinical outcome studies, for ease of refer-
ence it will be adopted for the rest of this discussion
because this investigation is based on a clinical inter-
vention study in which participants recruited were
diagnosed with schizophrenia and were called patients
in the setting in which they were treated.
METHOD
Context of the Family Psychoeducation
Study
This ethnic-sensitive family psychoeducation study
was a pilot study that I developed specifically for Chi-
nese Americans based on the cultural and contextual
Social Work Research Volume 40, Number 1 March 201654
needs of this immigrant population. It involved six
months of biweekly individual family treatment in
which the patient diagnosed with schizophrenia and
his or her caregivers were present, and a biweekly
relatives’ group for caregivers only. The study took
place at one of the biggest mental health agencies
serving the Asian population in a northeastern city
in the Untied States. Informed consent from the par-

ticipants and Fordham University institutional review
board approval were obtained. Details of the recruit-
ment process and the protocol are available in the
published outcome study ( Kung et al., 2012). The
inclusion criteria for the patients were that they be
Mandarin- or Cantonese-speaking Chinese, age 18
or over, with a schizophrenic form of disorder as
diagnosed by the treating psychiatrist, and with one
or more relatives willing to participate in the study.
Relatives also had to be 18 or older, speak Mandarin
or Cantonese, and either live with or contact the
patient at least once a month. They could be parents,
spouses, or siblings. Twelve families were enrolled in
the study. Nine were assigned to the intervention
group and three to the comparison group based
mainly on their geographic distance from the agency
and the caregivers’ fluency in Mandarin or Cantonese,
given that they were the languages spoken in the
relatives’ group. Session notes available from the nine
families in intervention group alone were examined
and reported in this study.
Two trilingual clinicians of Chinese descent were
involved in the intervention study. One was the agen-
cy’s therapist with a master’s degree in counseling
psychology and four years of full-time clinical experi-
ence. I was the other clinician, and the principal in-
vestigator, who became involved because it was hard
to recruit trilingual therapists (some young patients
spoke better English than Chinese). I have an MSW,
a PhD in social work, and nine years of full-time
clinical experience. I also provided weekly to biweekly
supervision to the agency therapist. The former
treated four families; the latter treated the remaining
five. Both clinicians co-led the relatives’ group.

Collection of Qualitative Data and
Analyses
Detailed session notes in English, also part of the
agency record, were used in this analysis. Family
session records documented case development, in-
terventions used, client responses, and tasks assigned.
Group session records reported psychoeducation
provided, group responses and process, questions
raised, and discussion. Intake summaries and family
and group session notes were analyzed for the pres-
ent report.
Two families had two caregivers participating
throughout the study; the remaining seven had one
enrolled caregiver. In addition, eight relatives who
initially did not enroll in the program were also in-
volved in one to four family sessions, and three ad-
ditional relatives came to the relatives’ group for one
to six sessions. Thus data included in this qualitative
study were based on nine patients and 19 relatives,
with records from 104 family sessions and 13 group
sessions.
Session notes were organized and analyzed using
the coding techniques and the constant comparison
method in grounded theory ( Corbin & Strauss,
2008). Qualitative analysis software ATLAS.ti (version
6.0) was used for data organization and retrieval.
I coded the data using open, axial, and selective cod-
ing line-by-line ( Charmaz, 2006). In coding the first
three cases, when new codes emerged I went back to
the previously coded cases and recoded. At the end,
all codes were grouped into broader categories. The
other clinician acted as the second coder. Due to time
and resource constraints, the second coder overlaid

her coding onto documents already coded by me,
using the developed code structure while adding new
codes as needed. Discussion between the two coders
ensued to negotiate differences in coding. Both cod-
ers wrote memoranda throughout the coding process
to facilitate later discussion and distillation of the
codes and categories ( Charmaz, 2006). I then went
through the documents a third time and applied the
final agreed-on streamlined code structure. Next, I
reread all the quotations under each code, reflecting
on emerging themes using memos written by both
coders. Triangulation from various angles was used
to ensure accuracy in capturing and interpreting the
complex realities ( Sands, Bourjolly, & Roer-Strier,
2007). The trustworthiness of the data interpretation
was also enhanced because both coders were familiar
with all the participants through involvement in the
relatives’ group, and I also supervised the second
coder’s clinical work.
FINDINGS
Participant Demographics
The patients’ average age was 32 (SD = 13.64; range:
18 to 51). Two-thirds were never married, and one-
third were married or in a live-in relationship at the
time of the study. Most patients resided with their
Kung / Tangible Needs and External Stressors Faced by Chinese
American Families with a Member Having Schizophrenia 55
immediate or extended families (88.9%); only one
lived in a residential facility for individuals with men-
tal illness. The caregivers’ relationship with the pa-
tients varied, including parents (53%), spouses, a

sibling, and a live-in boyfriend. The mean age of the
caregivers was 56 (SD = 12.38; range: 44 to 79), and
average schooling was 10 years (SD = 2.39). All re-
ported an annual family income of less than $40,000,
with two-thirds earning $20,000 or less. Although
the group came from mostly middle and lower mid-
dle class, the very low reported income was likely due
to retirement of some caregivers and to less-than-
reliable financial disclosure in others. Most relatives
were not recent immigrants; the median years of liv-
ing in the United States was 22 (range: 1.5 to 70).
Despite the length of migration, the participants, with
the exception of one patient who spoke better Eng-
lish than Chinese, had low acculturation based on
their English proficiency and the circle in which they
worked or socialized. No family dropped out of the
study. The mean number of family sessions conducted
was 9.78 (range: 3 to 14). On average, caregivers at-
tended 10 out of the 13 group sessions. Improvement
was noted at termination and at six-month follow-up
compared with the baseline for the intervention
group. Areas of improvement included patients’
symptomatology and quality of life, and caregivers’
knowledge of the illness, knowledge of treatment and
community resources, and social support. These im-
provements were greater in the intervention group
than the comparison group.
Tangible Needs and External Stressors
Major themes emerged regarding families’ tangible
needs and external stressors. Tangible needs included
housing, finance, study, and work, while external
stresses resulted from interacting with outside systems.
Also captured were patient and caregiver strengths.
All are discussed in detail in the following sections
with selected quotes cited from the session notes to

illustrate the points.
Stress from Housing. One of the most basic tan-
gible human needs and rights is decent housing.
However, many families had to live in very crowded
environments, which was a source of stress. Seven
out of the nine families lived with extended families
at some point in the past two years, and four still did
during the study. Without adequate physical space,
familial stress seemed exacerbated. In one family, due
to financial constraint, the patient and her parents
had to continue living with the married sister’s fam-
ily and her in-laws, even after the sister had died
more than a year ago. This further strained the al-
ready uncomfortable relationship. The housing issue
was finally resolved when the parents were granted
senior housing and the patient was placed in a resi-
dential facility for individuals with mental illness after
a brief stay at a shelter. However, the family contin-
ued to experience stress as the senior housing was in
a distant community with a high crime rate and no
Chinese-speaking neighbors. The patient also felt
insecure living by herself at the residential facility
due to language and cultural barriers. The family
wanted the whole family to live together so that they
could take care of each other. However, under the
current housing policy no such provision was avail-
able for families with an adult child. In another fam-
ily, the 23-year-old male patient who had delusions
and obsessions with sexual themes had to live with
his single mother in a studio in the basement with
no partition. The impact of the lack of privacy in
such an environment was hard to estimate as he
struggled with his sexual issues.

Financial Stress. Finance is at the core of many
tangible needs. For the majority of the families,
money was a major concern. During the family ses-
sions, only two out of eight families did not raise any
financial issues throughout: One had relatively stable
income, with the patient’s spouse being semiretired;
the other was a single working mother living with
her son with mental illness in a basement studio. It
is interesting to note that those most concerned
about money were not the poorest. In contrast, some
relatively affluent families who owned their small
businesses were very distressed about money. A pa-
tient’s obsessive worries about keeping her restaurant
business afloat and money lent to clansmen caused
much stress. In fact, this was the trigger for the onset
and relapses of her mental illness. Another family
having no means to pay for the day treatment pro-
gram suitable for the patient decided not to enroll
her because it was not covered by Medicaid.
The theme of finance actually inundated the treat-
ment process. These families’ daily struggles seemed
inseparable from money matters and were raised
rather frequently during individual family sessions.
Concerns were related to social security benefits,
including disability assistance, food stamps, and Med-
icaid. For one family, the patient and her parent’s
upcoming naturalization interviews in English be-
came a major stressor, because failing it would mean
denial of entitlement to more benefits. Entanglement
with extended families about money became the

central issue for two patients. They were upset by
the incessant financial demands from the in-laws.
Conflicts also arose within the family when the pa-
tients negotiated pocket money with their parents,
often complaining about their frugality. Money was
the theme for patients’ disturbing behaviors such as
stealing money from home, asking relatives for
money, spending sprees, and giving money away to
strangers. Because finance meant so much to these
mostly low-income families, related issues fueled
their stresses and reactivity.
Work and Study Stress. Work and study caused
much stress to the patients and the caregivers because
they relate not only to finances, but also to the indi-
viduals’ sense of worth. The stress stemmed from the
patients being pushed beyond their capacity, or they
took on too much, leading to increased symptoms
such as anxiety and temper tantrums. Some education-
related stress was caused by the parents’ high expec-
tations despite the patients’ disinterest or low
capacity. The parents wanted the patients to attain
higher education so that they could secure better jobs
and a better future instead of staying in the current
day treatment program or working at a sheltered
workshop. An 18-year-old patient had had a very
early onset of mental illness when he first migrated
to the United States at 10 years of age. His compro-
mised intellectual development and language barrier
added to his academic difficulty. The school suggested
that he enroll in a vocational school, but the parents
declined. They wanted him to be in a “normal regu-
lar school” because they valued education highly.
Even though both parents are aware that (pa-
tient) has made very limited progress academ-

ically and often feels stressed with study and
homework, they’d rather have him continue
his study at the current school. . . . Because of
the choice the parents made, client is stressed
out.
Another 21-year-old patient was “afraid of school
and had no interest in getting her GED or going to
college.” The mother, however, thought it would
be “better for [patient] to go to school to improve
her English and then find a long-term job.”
One patient’s pressure to work and study came
from herself. She wished to catch up with her peers’
educational attainment when hers was delayed be-
cause of her illness.
[Patient] still has a busy schedule, with piano
lessons, classes, internship, and going to the
gym. She is committed to all activities. . . . It’s
obvious that her tight schedule is wearing her
out.
Another patient’s work stress in running a restaurant
caused the onset and relapses of her mental illness.
The eventual selling of the business in the past year
put her and her spouse in a retired mode, thereby
reducing much stress for the couple. In some fami-
lies, the parents’ work demand, especially from their
own businesses and other child care responsibilities,
took a toll on them and they became less patient with
their ill children. These stressors were manifested in
behaviors of high “expressed emotions,” such as nag-
ging and criticism. It seemed that the self- or family-
imposed work and study stress is related to the need
to keep up with their own expectations or those of

their families to be able to earn a stable, decent living
in an environment in which they do not feel very
secure.
Stress and Constraints in Dealing with External
Systems. Tangible stressors not only came from
families’ concerns because of their own expectations
or lack of internal resources, they were also imposed
on them as they encountered external systems such
as government offices and social services agencies.
A family was petrified when it had to deal with the
judicial system. The 18-year-old male patient was
prosecuted for urinating in public. He had frequent
urges to urinate due to the side effects of the psy-
chotropic drugs. Only when the clinician wrote a
letter of appeal to the court on behalf of the family
explaining the patient’s condition was the charge
dropped, which brought great relief to the family.
Another patient, in her naturalization interview, was
further caught in a complicated situation.
Since [patient] mentioned she had a mental ill-
ness during the interview (as an explanation for
her unemployment during the past five years),
she was asked to produce a doctor’s note verify-
ing that her mental illness would not cause her
to harm herself or others.
This produced immense additional stress for the
patient and her family, with the lengthened wait
period and the sense that the naturalization process
seemed to involve endless hurdles and uncertainties.
This was one more hurdle for them after going

through the process of applying for financial assis-
tance and reinstating the cancelled Medicaid. These
are indeed very arduous processes, especially when a
language barrier is present. The high stakes involved
in obtaining the status and the resources intensified
the stress.
Constraints of Organizational Policies. Some
policies and practices within the social services
agency also caused constraints to patient develop-
ment. A high-functioning patient with a college
education obtained in China wanted to improve her
English to secure a job instead of staying at the day
treatment program. However, she was hesitant:
[Patient] was interested in the English class at
the community center, which takes place nine
to 12 Monday through Friday. However, she
expected not being allowed to attend the classes
while enrolled at [day program] given its em-
phasis on attendance. [Patient] was not ready to
leave [day program] as she admitted that it pro-
vided some security.
The agency’s concern over attendance also scaled
back her attempts in the job search. The unsettling
experience of a sudden disruption of Medicaid and
the feeling of uncertainty probably caused her to
opt for stability over venturing out for development.
On the whole, the external systems seemed unsym-
pathetic and unfavorable, imposing many threats and
constraints to these families. The language barrier
clearly exacerbated the stress.

Shortage of Alternative Services. For some pa-
tients, alternative or additional services were needed.
However, due to various systems’ constraints, many
patients were deprived of the resources. For ex-
ample, a day program with group treatment would
be appropriate for a patient in addition to individual
outpatient treatments.
Given [patient’s] bizarre appearance and behavior,
group treatment would be a good modality to
provide him feedback from others, reduce social
isolation, and [help him] acquire interpersonal
skills. These could eventually facilitate him to find
a partner and have normal sexual fulfillment.
However, there was no suitable group at the agency.
The patient, being bilingual, could join groups in
other non-Chinese-speaking agencies. According
to the policy, the whole case had to be transferred
out. The mother, being monolingual, could not use
help elsewhere. The transfer was thus aborted.
A 23-year-old patient required more structure
and supervision than the outpatient service could
provide. Moreover, the family was exhausted caring
for her. Residential care was needed, but there was
a dire shortage of placements for those who speak
Chinese. As a result, the family considered many
alternatives, including renting a place for her to live
by herself, moving her to the family’s basement, and
even marrying her off.
The shortage of services also affected some higher-
functioning patients who would benefit from voca-

tional training and better employment opportunities,
a desired goal for many patients and their families;
however, they were not available. One patient was
in a subsidized employment, but the pay was so low
that it could not cover even her transportation and
lunch expenses. This could hardly bring a sense of
fulfillment and independence to the patient and the
family.
Patient and Caregiver Strengths
Despite the many challenges related to the tangible
needs and external stressors, these families exhibited
enormous strengths in coping. The internal resources
of the patients and their families acted as buffers to
compensate for the shortage of external resources
and constraints.
Patient Strengths. The patients’ interests and hob-
bies, as well as their ability to maintain some daily
structures and activities, were their strengths. These,
in some cases, compensated for the lack of available
psychosocial services for monolingual clients. These
interests included art and design, literature, playing
mahjong, and surfing the Internet. Five out of nine
patients had religious faiths and were active in their
churches and temples. They also established friend-
ships from their academic and religious affiliations.
Some were high-functioning individuals before their
illness; for example, they cared for their families,
managed a restaurant business, or had high academic
attainments. These activities helped to sustain their
current functioning and a positive outlook.
Caregiver Strengths. Caregivers exhibited admi-
rable devotion to the care of their relatives and
showed a lot of strengths such as resourcefulness,

perseverance, and insight. Some families were re-
sourceful in using their own family businesses as
training grounds for patients when actual voca-
tional training or placements were unavailable. Such
arrangements provided some structure in the patients’
lives as they occasionally helped out in the stores.
Extended families also provided help. An uncle, who
was the brother of a single mother of a male patient,
came to the relatives’ group session during which the
patients’ sexuality and emotional intimacy needs
were addressed. This was especially relevant to this
patient as his psychotic symptoms had sexual themes.
The uncle could help to discuss these issues with the
patient, which would be difficult for the mother to
do with her young adult son.
A patient’s mother, separated from her husband,
came to the United States with her son to join her
family of origin. When faced with the onset of the
son’s illness, she went into a deep depression for one
and a half years requiring medication and support
from her extended family. When she rebounded,
she just pulled herself together, moved out with her
son, and started taking care of him by herself. She
did so admirably—with insight, acceptance, im-
mense patience, and devotion.
The mother states that she has learned a lot from
her own illness. She realizes how important it is
to take care of herself first before helping her
son. Nowadays she has learned to ignore, accept,

or go along with [patient’s] bizarre behaviors
without feeling frustrated, angry, or upset.
The caregivers were generally positive and insightful.
During the relatives’ group, members showed affirm-
ing attitudes toward the patients’ behaviors and were
supportive of each other. They pointed out the pa-
tients’ strengths; for example, they commented on
how one patient who had a habit of stealing was so
smart that she only stole from home. The group
members also indicated acceptance toward the pa-
tients’ problematic behaviors, because “it’s the illness,
you can’t blame the person with the illness.” They
concluded that “besides medication and treatment,
families’ love is the most critical factor to helping
patients get better.” Given the limited external re-
sources available to these families, caregivers’ re-
sourcefulness, devotion, and acceptance were really
the saving grace.
DISCUSSION
Migration, Vulnerability, and Culture
Although the family psychoeducation protocol
focused on the psychological and relational issues
within the families, when stresses of these Chinese
American families were closely examined, many were
found to be intricately related to their tangible needs
such as housing, finance, bureaucracies of external
systems, and lack of bilingual services. The numerous
needs seemed to spring from their relatively low SES.
The stakes involved in obtaining needed resources
such as Medicaid and welfare benefits are especially
high because they could be the families’ last resorts.
The families’ compromised ability to tap into available
resources and to navigate around the systems height-

ens their sense of insecurity. Thus disruption or denial
of these services causes immense anxiety. Such inse-
curity also leads to their tendency to hold on to as
many financial resources and benefits as possible. So,
even relatively affluent families tend to refuse to pay
out-of-pocket for needed services, which eventually
exacerbates their stress. The extreme prudence in
spending could be explained in part by these immi-
grants’ pressure to succeed economically in this coun-
try, because this was their “American dream” when
they migrated ( Louie, 2009). Some also have to sup-
port their relatives back in China.
Crowded living arrangements with no individual
bedrooms for the patients themselves greatly limit
the autonomy of the patients and deprive them of
the buffer of physical space against the diffuse bound-
aries among family members ( Kung, in press). The
Chinese culture expects unmarried children to live
with their parents ( Logan & Bian, 2004), a practice
that is in contrast to the housing policies in the
United States. In the current system, families are
placed in separate households or apartments depend-
ing on their categories of need, for example, older
adults or individuals with mental illness or other
special needs. Many families have expressed the de-
sire for public housing for unmarried adults with
SMI to live with their parents. This could ensure
physical space for privacy and autonomy while al-
lowing day-to-day support within the families.
Asian cultures have strong work ethics ( Harry,
2007). Aspiring to academic attainment is partly cul-
tural and partly a practical attempt to secure better
economic opportunities in a foreign land where racial
discrimination persists ( Gee, Spencer, Chen, Yip, &

Takeuchi, 2007). Sometimes a vicious cycle emerges
when the patients or the families cannot accept the
ill members’ limitations, thus causing additional stress
to both parties. The high aspirations in securing em-
ployment are unfortunately not supported by exist-
ing services provisions due to shortages in vocational
training and job placements for individuals with
mental illness ( Cook, 2006). The situation is far
worse among Chinese patients due to the lack of
bilingual services.
Dealing with the bureaucracy of government of-
fices and social services agencies intensifies the sense
of inadequacy in these immigrant families with spe-
cial needs. The systems tend to reinforce the sense
of helplessness in services users through their poli-
cies and regulations, sabotaging the patients’ and the
caregivers’ incentive to venture out for betterment.
Moreover, interacting with government officials is
anxiety provoking for many Chinese immigrants
because of the culture’s emphasis on social hierarchy
under Confucianism, with officials being the privi-
leged class who could make or break the individuals
( Lin, 1977). These immigrants face high-stakes sanc-
tions when they deal with the legal system, social
security offices, and the U.S. Citizen and Immigra-
tion Services.
Implications for Practice
Because the tangible needs and external stressors of

these families are so intertwined with their daily living,
they affect familial relationships and psychosocial well-
being. It is thus important for practitioners to enable
the families to gain access to needed resources to al-
leviate their stress. Given the patients’ compromised
cognitive ability because of the mental illness, and the
families’ difficulty in negotiating with the external
systems, the clinicians’ mediating role and case man-
agement function to connect them to resources is of
paramount importance ( Test et al., 1997). However,
in the recovery movement literature, which has taken
center stage in the past decade on debates of rehabili-
tation for patients with SMI, emphasis is put on fa-
cilitating them to regain autonomy in the community
by reducing the case managers’ roles in “managing”
people’s lives ( Davidson, Rowe, Tondora, O’Connell,
& Lawless, 2008). To regain true dignity and indepen-
dence so that the patients can really “live, work and
love in the community” ( Ridgway, McDiarmid,
Davidson, Bayes, & Ratzlaff, 2002, p. 5), employment
opportunities, housing, adequate financial assistance,
and psychosocial rehabilitation services are needed.
For the vulnerable immigrant Chinese Americans,
assistance to access these resources through case man-
agers cannot be overemphasized.
Furthermore, the availability of resources could
alter the families’ appraisal of stressors, enhance their
perceived coping capacity, and thereby reduce the
stress they experience ( Lazarus & Folkman, 1984;
Zegwaard et al., 2011). Intervening at this level not
only alleviates the families’ immediate stress, but also
increases their confidence in the clinicians’ helpfulness
and competence, thereby increasing their openness
to address other psychosocial issues, which would

facilitate patient recovery ( Kondrat & Teater, 2012).
As a result of the bureaucracy of many service pro-
viders and government agencies and the lack of bi-
lingual services, mental health professionals’ advocacy
role at the individual level on behalf of the families
and at the policy and services provision levels is im-
portant. At the individual level, clinicians sometimes
have to struggle to discern whether to take the direct
advocate’s role on behalf of the clients or to facilitate
clients to advocate for themselves. The former usu-
ally yields quicker results and spares clients of the
anxiety in waiting, but the latter could have a more
lasting effect as clients feel more empowered when
they learn how to advocate for themselves. Practi-
tioners also need to navigate between directly alle-
viating families’ emotional distress by providing
practical help, such as rehearsing for the naturaliza-
tion interview, and indirectly assisting them to find
other ways to handle external demands. Many Chi-
nese families do not have a clear idea of the roles of
social workers, and sometimes perceive them as
teachers ( Pearson, 1993). Although clinicians do not
want to neglect clients’ immediate needs, negotiating
with and educating them on the practitioners’ ap-
propriate roles is necessary. At the macro level, ad-
vocacy to meet pressing needs such as more bilingual
vocational training and job placement services, resi-
dential care, psychosocial programs, and culturally
sensitive housing policies for single adults to live with
their families are important.
This investigation was conducted in the context of
a family psychoeducation study aimed mainly at clin-
ical interventions at the micro level addressing psycho-
logical and relational issues within the family. However,

careful examination of the families’ stressors indicated
the need to also intervene at the mezzo and macro
levels. The intense tangible needs and external stressors
in this immigrant population with low SES highlight
the need to address the clients’ issues in relation to the
larger environment in which they reside, to bring
about relief and change. This coincides with recent
studies that found positive results when combining
family psychoeducation programs with assertive com-
munity treatments, which attended to both family
relationships and supporting patient functioning in the
community ( McFarlane, Lynch, & Melton, 2012).
For the family psychoeducation model for Chinese
Americans, based on the findings, some modifications
could be made. First, clinicians can spend more time
introducing community resources as part of the edu-
cational components in addition to information about
the causes and the course of schizophrenia. Through-
out the treatment process, practitioners should also
explore more on the families’ tangible needs and ex-
ternal stressors and connect them to resources and
advocate with them and on their behalf for needed
services. As some of these families are rather resource-
ful, we can explore their assets within the family—
and from relatives and friends—such as informal
vocational training opportunities. Throughout the
relatives’ group, we can encourage members to share
their challenging and successful experiences interact-
ing with the external systems so that they can gain
practical and emotional support from each other. It
was observed in the relatives’ group that relatives can

really identify with each other’s needs and experi-
ences, and the sharing was empowering to both the
givers and the receivers. As we zero in on the various
challenges faced by these Chinese families, we must
not lose sight of their enormous strengths and recog-
nize the patients’ competence before they fell ill, and
the strengths, devotion, and resourcefulness of the
family members.
Implications for Research and Limitations
of the Study
Tangible needs and external stressors faced by im-
migrant Asian or Chinese families with a member
having schizophrenia have been overlooked. This
study addressed this knowledge gap. Through an in-
tervention study over a period of time, rich data on
the clients’ needs and stressors were collected from
the therapists’ repeated encounters and in-depth
knowledge of the families’ ongoing struggles, which
could not be obtained otherwise ( Swartz, 2006). The
value of session notes in clinical treatments to under-
stand the prevalent themes of client needs and issues
is affirmed. Such detailed accounts of the families’
needs and the clinicians’ possible roles help to embel-
lish the intervention protocol for future studies.
Despite the valuable contributions of this study to
practice and research, some limitations exist. Al-
though the session notes provide rich data on the
families’ stress and the clinicians’ roles, they are not
a complete documentation of what transpired in the
session, unlike video or audio recordings. The clini-
cians’ bias of what to record also affects the accuracy
of the reality depicted ( Floersch, 2000). Fortunately,
as both therapists in the study know the families’

situations through the relatives’ group, and I also su-
pervised the other clinician’s practice, bias was re-
duced by multiple perspectives and multiple contexts.
Furthermore, as the clinical work was done mainly
in Chinese and the session notes were written in
English, translation of the contents is a legitimate
concern. However, because both clinicians are pro-
ficient in both languages and are used to document-
ing agency records in English, this did not pose a
problem.
Although the number of session notes used was
sizable (117 in total), the actual number of partici-
pants involved was small (9 patients and 19 relatives),
which may limit the study’s representation. More-
over, due to resource constraints, the second coder
did not do the coding separately but overlaid hers
on the first coder’s. It is likely that the second cod-
er’s coding was affected by that of the first coder,
although she was encouraged to develop additional
codes as appropriate. Fortunately, lavish memoran-
dums written by both coders facilitated the discus-
sion between them before the coding was finalized.
Last, although the participants in this study were
rather diverse in terms of immigration history, their
overall acculturation level was low, and they were
all of lower to lower-middle-class SES. Thus the
findings are generalizable to this group.
SUMMARY AND CONCLUSION
This inquiry addressed the knowledge gap of the
understudied population of Chinese American
families with a member living with schizophrenia,
and the understudied areas of their tangible needs
and external stressors. This group’s low SES and low
acculturation posed enormous stress to meet their

tangible needs pertaining to housing, finance, work,
and study, and to interact with the external systems.
The rigidity of the bureaucracy, culturally insensitive
policies, and lack of bilingual services aggravated
their challenges. To attain the recovery movement’s
ideal of increasing these individuals’ autonomy in
the community, adequate social services need to be
put in place—including bilingual psychosocial pro-
grams such as day treatment, job training, employ-
ment opportunities, and residential services. To
assist this clientele to navigate around the systems,
the clinicians’ active role in case management and
advocacy is very important. Moreover, to combat
the “culture of chronicity” ( Davidson et al., 2008),
service providers and agency policies need to steer
away from the tendency to control and microman-
age, which impedes patient growth and autonomy.
This study also highlights the value of taking the
person-in-environment perspective in addressing cli-
ents’ needs at various levels to attain lasting changes.
Despite the challenges, many devoted caregivers
manage to support the patients in the community
with their meager financial resources and external
support, though sometimes at the expense of patient
development and caregiver well-being. For research
implications this investigation, based on session notes
from an intervention study over a period of time,
proved to be a viable approach to obtain in-depth
knowledge on a clientele in distress.

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Unit 5 Assignment Details
Greening the Message: Ethical Decision-Making
In this Assignment, you will culminate two Course Outcomes by
evaluating an ethical dilemma within the Capsim Core
simulation concept:
MT460-3: Formulate strategic business decisions from a
management, leadership and organizational design perspective.
GEL 7.5: Evaluate ethical rules applicable to the field of study.
A growing concern in business today is how to become
environmentally friendly or “green.” At times a management
team may find itself torn between what it perceives as good for
the company and what’s good for the environment. For access to
resources that can aid your leadership and management
decision-making in this assignment, visit the MT460:
Management Policy and Strategy Knowledge Resources folder.
Scenario:
Watch the following video presenting an ethical dilemma you
face as leader of your Capsim Core simulation business:
“Greening the Message.”
(https://drive.google.com/file/d/1VQF9XjW0_oLXYdWjNddukq
HOBlCZwBF6/view) The company has developed a new
production process, which reduces the use of electricity and
labor. Upon hearing the news, the marketing team is eager to
launch a new marketing campaign that outlines this
development by capitalizing on consumer demand for products
that support “sustainability.” The problem is the facility's waste
output has not been reduced. Discussions with General Counsel,
the Board of Directors' Executive Steering Committee, a

company-wide task force, and the Marketing team leave you
with only 4 courses of actions. As the leader of your
organization, you are presented with four options to address this
ethical dilemma. Your job is to make a strategic decision that
will have an effect on company performance in the future:
a) Do nothing.
b) Allow marketing to launch the campaign in an effort to "buy
sometime" while you implement additional cost controls, and
begin to revamp new product development. You believe waste
qualifications are not likely to be challenged in the near term.
c) Despite protests from the marketing department, utilize the
green message in a corporate- oriented campaign,
acknowledging improved energy efficiency and honestly stating
that production waste has not yet been decreased but that the
company is working to achieve that, too.
d) Discard the green message altogether and launch a campaign
that focuses on changes that have made the company more
energy efficient.
Assignment Instructions:
You will be presented with this ethical dilemma in Round 2 of
the Capsim Capstone Competition simulation. Analyze the
“Greening the Message” ethics scenario you are presented with
in the simulation from a strategic management and strategic
leadership perspective. You will be challenged with creating a
plan that directs your management team on the decisions
regarding the ethical dilemma as proposed in the
“sustainability” marketing campaign. Using the following
Assignment checklist, prepare a brief business report to your
management team detailing your strategic management and
leadership position on this ethical dilemma.
Assignment Checklist:
· Provide a synopsis of the ethical dilemma using ethical
theories, principles, and concepts.
· Reconcile conflicts in the development of your strategic
decision-making using Agency Theory and Stakeholder Theory

concepts and principles.
· Explain how ethical theories should guide the implementation
of your strategic decisions.
· Using the strategic planning process, create a plan detailing
your leadership and management decisions on the ethical
dilemma.
· Using inductive reasoning skills, explain how your decisions
will build competitive advantage using the strategic
management hierarchy.
· Formulate and explain the company's positioning strategy
based on your strategic management and strategic leadership
decisions.
· Use strategic analysis tools to demonstrate proficiency and to
provide reasoning for your decision-making.
· Use a minimum of three scholarly research resources to help
substantiate your position.
· Apply proper APA style format. Be sure to use headings and
subheadings to create a flow of ideas and topics within your
writing.
· Apply Expository writing style to develop your business
report. You should write in third person to avoid bias in the
dissemination of your strategic management and strategic
leadership positions.
Here is the Unit 5 Assignment grading rubric.
Directions for Submitting Your Assignment
· Before you submit your Assignment, you should save your
work on your computer in a location and with a name that you
will remember.
· Make sure your Assignment is in the correct file format
(Microsoft Word .doc or .docx).
· Submit your completed document to the Unit 5 Assignment
Dropbox.

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R E V I E W
open access to scientific and medical research
Open Access Full Text Article
http://dx.doi.org/10.2147/PRBM.S111593
Optimizing psychosocial interventions in
first‑episode psychosis: current perspectives

and future directions
Nicholas JK Breitborde1,2
Aubrey M Moe1
Arielle Ered3
Lauren M Ellman3
Emily K Bell4
1Department of Psychiatry and
Behavioral Health, 2Department of
Psychology, The Ohio State University,
Columbus, OH, 3Department of
Psychology, Temple University,
Philadelphia, PA, 4Department of
Psychiatry, University of Arizona,
Tucson, AZ, USA
Abstract: Psychotic-spectrum disorders such as schizophrenia,
schizoaffective disorder, and
bipolar disorder with psychotic features are devastating
illnesses accompanied by high levels of
morbidity and mortality. Growing evidence suggests that
outcomes for individuals with psychotic-
spectrum disorders can be meaningfully improved by increasing
the quality of mental health
care provided to these individuals and reducing the delay
between the first onset of psychotic
symptoms and the receipt of adequate psychiatric care. More

specifically, multicomponent treat-
ment packages that 1) simultaneously target multiple
symptomatic and functional needs and
2) are provided as soon as possible following the initial onset of
psychotic symptoms appear
to have disproportionately positive effects on the course of
psychotic-spectrum disorders. Yet,
despite the benefit of multicomponent care for first-episode
psychosis, clinical and functional
outcomes among individuals with first-episode psychosis
participating in such services are
still suboptimal. Thus, the goal of this review is to highlight
putative strategies to improve care
for individuals with first-episode psychosis with specific
attention to optimizing psychosocial
interventions. To address this goal, we highlight four
burgeoning areas of research with regard
to optimization of psychosocial interventions for first-episode
psychosis: 1) reducing the delay
in receipt of evidence-based psychosocial treatments; 2)
synergistic pairing of psychosocial
interventions; 3) personalized delivery of psychosocial
interventions; and 4) technological
enhancement of psychosocial interventions. Future research on

these topics has the potential to
optimize the treatment response to evidence-based psychosocial
interventions and to enhance
the improved (but still suboptimal) treatment outcomes
commonly experienced by individuals
with first-episode psychosis.
Keywords: first-episode psychosis; multicomponent care;
psychosocial treatment; personal-
ized medicine
Introduction
Psychotic-spectrum disorders such as schizophrenia,
schizoaffective disorder, and
bipolar disorder with psychotic features are devastating
illnesses accompanied by
high levels of morbidity and mortality. Under usual systems of
care, these disorders
are characterized by repeated symptomatic relapses,1–3
elevated rates of psychiatric
comorbidities such as anxiety, depressive, and substance use
disorders,4,5 reduced rates
of participation in competitive occupational and educational
activities,6–8 severe deficits
in cognitive abilities,9–11 rates of death by suicide up to 12
times greater than popula-

tion norms,12,13 and a life expectancy reduced by up to 25
years14,15 due primarily to
cardiovascular, infectious, and pulmonary diseases.13,16 The
severity of these disorders
was recently highlighted within the Global Burden of Disease
(GBD) Study.17–19 As part
Correspondence: Nicholas JK Breitborde
Department of Psychiatry and Behavioral
Health, The Ohio State University, 1670
Upham Dr., Columbus, OH 43210, USA
Tel +1 614 685 6052
Email [email protected]
Journal name: Psychology Research and Behavior Management
Article Designation: REVIEW
Year: 2017
Volume: 10
Running head verso: Breitborde et al
Running head recto: Psychosocial interventions in first-episode
psychosis
DOI: http://dx.doi.org/10.2147/PRBM.S111593
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Breitborde et al
of a larger effort to quantify the deleterious effects of various
health conditions worldwide, the GBD Study assigns a dis-
ability weight to over 300 illnesses and injuries – a numerical
value indicating where a particular health state exists on a
range from 0 (i.e., a state of perfect health) to 1 (i.e., a health
state equivalent to death). Within the two past iterations of
the GBD study, the acute presentation of schizophrenia – the
prototypical psychotic-spectrum disorder – where active hal-
lucinations and delusions are present was assigned the highest
disability weight among all illness and injuries.20,21 In fact,
while achieving remission of hallucinations and delusions is
often considered a “treatment success” for individuals with
schizophrenia,22,23 this health state (i.e., schizophrenia in its
residual state) was assigned the ninth highest disability weight

among all illnesses and injuries in the GBD study.20,21 When
a “successful” treatment outcome equates to the ninth worst
health state that humans can experience other than death, there
is significant room for improvement in existing treatments for
a given disorder.
Growing evidence suggests that outcomes for individu-
als with psychotic-spectrum disorders can be meaningfully
improved by increasing the quality of mental health care pro-
vided to these individuals and reducing the delay between the
first onset of psychotic symptoms and the receipt of adequate
psychiatric care.24,25 More specifically, multicomponent
treatment packages that 1) simultaneously target multiple
symptomatic and functional needs and 2) are provided as
soon as possible following the initial onset of psychotic
symptoms, appear to have disproportionately positive effects
on the course of psychotic-spectrum disorders.26,27 To date,
numerous trials of multicomponent treatment packages for
individuals early in the course of a psychotic-spectrum disor-

der – a period frequently referred to as “first-episode psycho-
sis”28 – have been completed by independent research teams
across four continents. Although there is some variation in
the results, overall, these studies suggest that multicomponent
care for first-episode psychosis may produce improved out-
comes across numerous psychiatric (e.g., positive symptoms,
negative symptoms, and depressive symptomatology) and
functional domains (e.g., cognition, social functioning, and
participation in competitive work and school).29–40 In response
to these findings, multicomponent care provided as soon as
possible following the first onset of psychotic symptoms is
now recognized as the new “gold standard” in the treatment
of psychotic-spectrum disorders. Such treatment programs
are now available in every continent with the exception of
Antarctica,41,42 and several countries have launched federally-
supported efforts to disseminate multicomponent care for
first-episode psychosis nationwide.43–45 For example, between
fiscal year 2014 and 2016, the federal government of the USA

dedicated nearly $100 million to support the dissemination
of Coordinated Specialty Care for first-episode psychosis – a
multicomponent treatment program comprised of individual
psychotherapy, family psychoeducation, medication manage-
ment, and supported employment and education.46
A key contribution of the recent movement toward multi-
component treatment programs for first-episode psychosis is
increased recognition of the value of psychosocial interventions
for psychotic-spectrum disorders. Although existing treatment
guidelines typically identify pharmacological treatment as the
“cornerstone” or “first-line” treatment of psychotic-spectrum
disorders,47–49 there is growing recognition that medication
alone cannot fully ameliorate the morbidity and mortality
associated with these disorders.50–53 For example, while anti-
psychotic medications have clear efficacy with regard to the
treatment of psychotic symptomatology,54,55 available
evidence
suggests that such symptoms may account for <1% of the
illness-related disability experienced by individuals with first-

episode psychosis (Moe and Breitborde, unpublished data,
2017). Effects of antipsychotic medication on other meaningful
outcomes in psychotic-spectrum disorders (e.g., employment,
cognition, and social functioning) are small and may not be
clinically significant.11,51,56,57 Current multicomponent
treatment
programs for first-episode psychosis emphasize a combination
of psychosocial and pharmacological interventions as first-line
treatment58,59 and available data have demonstrated that such
combined treatment produces improved outcomes among
individuals with psychotic-spectrum disorders – including first-
episode psychosis – when compared with medication alone.60–
62
Yet, despite the benefit of multicomponent care for first-
episode psychosis, clinical and functional outcomes among
individuals participating in such services are still subop-
timal.26,63,64 Among such individuals, inpatient psychiatric
hospitalizations are common,31 substance use – especially
tobacco – is high,29 poor physical health outcomes are the

norm,65 and rates of participation in competitive employ-
ment remain lower than their age-matched peers without
psychotic-spectrum disorders.30 Consequently, there is still
significant room for improvement in the treatment of first-
episode psychosis.26,63
Thus, the goal of this review is to highlight putative
strategies to improve care for individuals with first-episode
psychosis with specific attention to optimizing psychosocial
interventions. To address this goal, we highlight several opti-
mization strategies with the potential to enhance the benefits
associated with these interventions. In particular, we focus
our review on burgeoning areas of research with regard to
optimization of psychosocial interventions for first-episode
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121
Psychosocial interventions in first‑episode psychosis
psychosis and avoid reviewing strategies that are already
clearly documented elsewhere (e.g., building a strong thera-
peutic alliance66 and addressing the comorbid psychiatric
symptoms, functional deficits, and cognitive decline that
accompany first-episode psychosis67–73).
Strategy 1: reduce the delay
in receipt of evidence-based
psychosocial treatments
Within the first-episode psychosis literature, there is a clear
association between the duration of untreated psychosis
(DUP; i.e., the time between the first onset of psychotic
symptoms and the receipt of adequate mental health care)
and the course of psychotic-spectrum disorders. More spe-
cifically, a longer DUP is associated with a worse course of
illness and poorer response to treatment.25,31,32,74 Many stud-

ies have defined the endpoint of the DUP (i.e., the receipt
of adequate mental health care) as participation in some
duration of antipsychotic medication.75,76 However, time
until the start of evidence-based psychosocial interventions
may also be an important endpoint following the first onset
of psychotic symptoms. For example, in a seminal paper, de
Haan et al76 examined the association between the duration of
time between the first onset of psychotic symptoms and the
first receipt of intensive psychosocial treatment (i.e., delay
in intensive psychosocial treatment [DIPT]) and the course
of schizophrenia. Given the limited availability of evidence-
based psychosocial treatments for psychosis in usual care
settings,77 it is not surprising that de Haan et al found that
the mean DIPT (19 months) was nearly twice as long as the
mean DUP (8.6 months). Among their sample, there were
positive univariate associations between negative symptoms
at 6-year follow-up and both DUP and DIPT (i.e., greater
negative symptoms associated with longer DUP and DIPT,

respectively). However, in multivariate analyses simultane-
ously examining DUP and DIPT, only DIPT was found to
be a statistically significant predictor of negative symptoms
at 6-year follow-up. These results raise the possibility that
reducing the delay between the first onset of psychotic
symptoms and the receipt of evidence-based psychosocial
care may be a modifiable risk factor through which providers
can improve the course of psychotic-spectrum disorders. This
hypothesis comports with data suggesting that individuals
earlier in the course of psychotic-spectrum disorders have a
greater response to psychosocial treatments when compared
with individuals with more longstanding illnesses.78–80
Despite the potential importance of DIPT to the course
of psychotic-spectrum disorders, we are unaware of any
subsequent studies that have investigated this concept in the
13 years since the paper by de Haan et al.76 Consequently,
there is a great utility for additional research to clarify the
association between delay in access to psychosocial treat-

ments and the course of psychotic-spectrum disorders. In
addition, psychiatric service research may benefit from
examining how evidence-based psychosocial services can be
incorporated within inpatient psychiatric settings. Although
the inpatient psychiatric unit is often the first care setting for
individuals with first-episode psychosis,81 evidence-based
psychosocial treatments for first-episode psychosis are
typically available in outpatient settings only. Thus, incor-
porating specialized psychosocial treatments in inpatient
settings may be an important strategy in reducing delay of
appropriate psychosocial care.
Strategy 2: synergistic pairing of
psychosocial interventions
Kern et al62 have highlighted that although numerous
evidence-based psychosocial interventions are available
for psychotic-spectrum disorders, no single psychosocial
intervention is sufficient to address numerous health and
functional consequences associated with these disorders.
Thus, there is growing interest in examining how best to pair

psychosocial interventions to improve outcomes among indi-
viduals with first-episode psychosis. Although research in this
area is still developing, promising results from the broader
literature on psychotic-spectrum disorders are already avail-
able with regard to effective pairing of psychosocial interven-
tions with cognitive remediation – an intervention defined
by the 2010 Cognitive Remediation Experts Workshop as “a
behavioral training based intervention that aims to improve
cognitive processes (attention, memory, executive function,
social cognition, or metacognition) with the goal of durabil-
ity and generalization.” To date, studies have examined the
benefits of pairing cognitive remediation with several addi-
tional psychosocial interventions, including work therapy
and supported employment programs,82–84 functional skills
training,85 and even an aerobic exercise program.86
Bell et al82 examined a combined cognitive remediation
and work therapy program, which involved individuals with
schizophrenia or schizoaffective disorder being randomly

assigned to receive cognitive remediation – characterized by
completion of computerized cognitive exercises and weekly
processing groups – plus work therapy or work therapy alone
for 6 months. Although both groups showed improvements,
individuals in the cognitive remediation and work therapy
group evidenced greater mean differences and larger effect-
size changes on cognitive performance, including working
memory, attention, and executive functioning. An additional
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Breitborde et al
study by the same group83 using the same methodology but

with an extended treatment period of 1 year similarly revealed
that individuals who received combined cognitive remedia-
tion and work therapy had significantly better performance
on measures of executive functioning and working memory
post-treatment compared with those who received work
therapy alone. In a sample of 44 individuals with schizo-
phrenia, McGurk et al84 compared the effects of 12 weeks
of supported employment and computerized cognitive
training against supported employment alone. Post-treatment
cognitive testing revealed that those in the combined cogni-
tive training plus supported employed group performed
significantly better on an overall composite cognition score
than those receiving supported employment alone, and that
these individuals in the combined condition also showed
significant reduction in depression and autistic preoccupa-
tion and better work outcomes compared with individuals in
the supported employment-alone condition. The functional
outcome improvements, particularly in work functioning,

can be directly attributed to the addition of cognitive reme-
diation in this case, as all other aspects of treatment were
matched. Although work training and supported employment
programs target work functioning directly, the addition of
cognitive training led to greater levels of employment, more
hours worked, and better functioning at work in individuals
with schizophrenia. In addition, those receiving cognitive
remediation also showed improvement in other domains (i.e.,
symptom levels and neurocognitive functioning).
In an additional study, Bowie et al85 randomly assigned
individuals with schizophrenia to receive cognitive remedia-
tion, functional adaptation skills training, or a combination
of both treatments. Although improvements in neurocogni-
tion were observed in both the cognitive training and com-
bined treatment groups and social competence significantly
improved in the functional skills and combined treatment
group, the combined treatment group showed significantly
greater improvements in functional competence and real-

world community activities than either the functional skills
training and cognitive remediation-only groups. Importantly,
the durability of these gains was greatest in the combined
treatment group. Taken together, these results suggest that
a combined treatment approach may produce better gains
across domains that are more likely to persist over time.
The utility of combining cognitive remediation and
physical activity has also been explored. In a recently
published pilot study,86 individuals early in the course of a
schizophrenia-spectrum disorder were randomly assigned
to 10 weeks of either cognitive training alone or cognitive
training combined with aerobic exercise sessions. Even with a
small sample and short training period, individuals receiving
combined cognitive training and exercise demonstrated larger
gains in overall cognitive abilities compared with participants
receiving cognitive training alone. These preliminary data
suggest that a combination approach including both exercise
and cognitive remediation allows for even larger gains in

cognition than cognitive remediation alone.
Thus, research on cognitive remediation has highlighted
strategies to increase the size, breadth, and durability of
treatment effects via the deliberate pairing of psychosocial
interventions. These findings are especially relevant to the
treatment of first-episode psychosis given the improved,
but still suboptimal benefits associated with current mul-
ticomponent treatment programs64 and questions about
the durability of these benefits after discharge from such
multicomponent treatment programs.87,88 Moreover, within
most multicomponent treatment for first-episode psychosis,
decisions with regard to psychosocial intervention uptake are
typically individual preferences of providers and individuals
with first-episode psychosis. Although such preferences are
valuable – especially those of individuals with first-episode
psychosis – future research exploring how specific psy-
chosocial interventions can be synergistically paired may
enhance clinical outcomes among individuals participating

in multicomponent care for first-episode psychosis.
Strategy 3: personalized delivery of
psychosocial interventions
Within the larger psychiatric literature, there is significant
interest in advancing personalized medicine89 – “the prescrip-
tion of specific treatments and therapeutics best suited for an
individual taking into consideration both genetic and environ-
mental factors that influence response to therapy”.90 The treat-
ment decisions resulting from these considerations fall under
the categories of “macrotreatment” and “microtreatment”
decisions.91 Macrotreatment decisions are those that guide
selection of specific interventions, whereas microtreatment
decisions guide the delivery of specific aspects of an inter-
vention. Given the heterogeneous presentation and course of
psychotic-spectrum disorder,92–94 personalized prescription of
psychosocial intervention may help to maximize treatment
outcomes among individuals with first-episode psychosis.
In recent years, there has been increasing focus on
research suggesting that genetic variants associated with

psychosis can be used to guide antipsychotic medication man-
agement decisions.95 Genetic variants could also potentially
be used to guide macrotreatment decisions concerning which
psychosocial interventions are prescribed to specific indi-
viduals with first-episode psychosis. For example, growing
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research has considered whether an individual’s response to
cognitive remediation may be moderated by genetic factors.
To date, several studies have examined whether response to

cognitive remediation may be predicted by the catechol-O-
methyltransferase (COMT) gene via its putative influence
on prefrontal dopamine functioning.96–98 However, results
from these studies are equivocal. There is some evidence that
response to cognitive remediation among individuals with
first-episode psychosis may be influenced by the expression
of genes involved in memory and synaptic plasticity (e.g.,
activity-regulated cytoskeleton-associated protein [ARC]).
In one recent study,99 individuals identified as carriers of
the ARC T allele showed significant improvement in overall
cognitive functioning after participating in metacognitive
remediation therapy, whereas non-T-carriers did not.
Another potential characteristic that could be used to
personalize psychosocial intervention prescription for indi-
viduals with first-episode psychosis is personality traits. It
has been demonstrated that non-pathological personality
traits are associated with course of illnesss and subjective
experiences of symptoms in individuals with psychosis,100

as well as other relevant correlates of psychotic-spectrum
disorders such as social cognitive abilities.101 A framework
for considering both research and theory of personality
in first-episode psychosis intervention decisions has been
proposed102 that would first involve formal assessment of
personality characteristics. These assessment data could
then be used to inform macrotreatment decisions, such as
choice of intervention formats (e.g., group interventions,
caregiver involvement) and microtreatment decisions, such
as how to tailor interventions for specific individuals to best
address their unique symptomatology, functional deficits,
and treatment goals.
Finally, the typical emergence of psychotic symptoms
in the late teens to early 20’s103 raises the possibility that
psychosocial interventions for first-episode psychosis may
be enhanced by tailoring them to the unique needs of indi-
viduals in this developmental stage. In his seminal writings,
Arnett has referred to this developmental stage as “emerging

adulthood” and has described it as “a period characterized by
change and exploration for most people, as they examine the
life possibilities open to them and gradually arrive at more
enduring choices in love, work, and worldviews.”104 Draw-
ing on this research, McGorry et al have advocated for the
development of youth-friendly mental health services that
promote shared decision-making in treatment and emphasize
social and vocational outcomes (as opposed to symptomatic
remission) as key treatment goals.105,106 Such characteristics
are not only consistent with the norms of this developmental
stage (e.g., movement toward greater autonomy and estab-
lishing the foundation for longstanding vocational and rela-
tionship roles) but may also play a role in whether emerging
adults access and remain engaged in specialized services for
first-episode psychosis.105 For example, early evidence from
existing youth-friendly mental health services suggests that
they may be successful in increasing rates of youth and young
adults from traditionally underserved populations who choose

to access mental health services.107,108
Strategy 4: technological
enhancement of psychosocial
interventions
Another promising avenue for optimization of psychosocial
treatment for first-episode psychosis involves integration
of technological advances. Although clinical research has
benefitted for several decades from emerging imaging
and psychophysiological measurement technologies, these
advancements are increasingly proliferated into people’s
typical, everyday activities (e.g., smartphones, digital
streaming technologies, and fitness trackers equipped with
heart-rate monitors). As these technologies continually
interface with normative human activities, they represent an
important avenue for advancement and expansion of health
care and treatment. Interventions delivered via technology
or technology-enhanced treatment may be a cost-effective
way to provide personalized, flexible, and evidence-based
interventions directly to individuals in their communities
or homes.109 The use of technology-enhanced treatment

has a myriad of potential clinical benefits for individuals
with first-episode psychosis, including the capability of
providing real-time cues to engage in particular behaviors
as a compensatory mechanism for memory deficits (e.g., to
encourage medication adherence110), as well as the ability
to alert individuals to physiological early warning signs of
symptomatic exacerbations in a personalized manner (e.g.,
changes in heart-rate variability111).
Although the use of technological advancements in
psychiatric treatment is in its relative infancy,112 the ready
availability and sophistication of these technologies is prom-
ising. This has been particularly true for smartphones and
apps, which represent one of the most rapidly expanding and
adopted forms of technology in human history.113 Available
research suggests that up to 90% of individuals with first-
episode psychosis have access to smartphones.114,115 Given
the
wide availability of this technology, these devices are ideal

for assessment of in vivo experiences of individuals with
psychosis. Ecological momentary assessment (EMA) – a
method for collecting information on naturalistic behaviors
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Breitborde et al
and experiences that has previously been done with paper-
and-pencil methodology – has been enhanced by the use of
smartphones. Smartphones offer participants the opportunity
to record information about their symptoms, feelings, and
thoughts in an immediately accessible forum that can auto-
matically sync with an external database. This approach can

mitigate the impact of cognitive deficits on memory and
recall, and can also provide cues for individuals to engage
in reflecting on internal processes and recording information
that can minimize the impact of deficits in the initiation of
behaviors that accompany psychotic-spectrum disorders.
Further, research suggests that symptom ratings collected
from individuals with psychosis via smartphone technology
have greater concordance with clinician ratings compared
with self-ratings made with paper and pencil.116 In addition
to being used to enhance treatment via self-monitoring,
smartphone technology can also be used to deliver interven-
tions directly to individuals with psychosis. Ben-Zeev et al117
recently investigated the efficacy of a smartphone-based
treatment to people with schizophrenia. This intervention was
designed to provide automated real-time/real-place illness
management support to individuals and was found to produce
improvements in mood regulation, medication adherence,
social functioning, and sleep. The demonstrated feasibility,

acceptability, and preliminary efficacy of this smartphone
intervention for schizophrenia offer promise for extending
evidence-based treatment for first-episode psychosis beyond
physical clinics and into the literal pockets of individuals via
widely available smartphone technology. As the benefits of
specialized care for first-episode psychosis may disappear
when young adults return to usual care,87,88 the extension
of evidence-based psychosocial treatment via smartphone
technology could potentially be leveraged to increase the
durability of the benefits produced by such specialized, but
typically time-limited, care.
Of note, the possibilities for integration of technology into
psychosocial treatment for first-episode psychosis also extend
to social media more broadly. For example, Alvarez-Jimenez
et al118 developed HORYZONS, an online intervention specif-
ically for youth with first-episode psychosis. Individuals with
first-episode psychosis could engage in a variety of interac-
tive psychosocial interventions on this moderated forum and

were also able to engage in peer-to-peer social networking.
Results indicated that this approach was feasible, engaging,
and safe for participants. The use of online forums to enhance
other psychosocial treatments for first-episode psychosis is
especially attractive, given its cost-effective nature, as well
as its potential to provide ongoing support that may prevent
disengagement from clinical services.
Technological advances are an evolving and exciting area
for clinical service delivery. However, the importance of an
evidence-based approach to treatment should not be forgotten.
Thus, there is a great need for additional research of smart-
phone and other technology enhancements for first-episode
psychosis. In the interim, mental health providers should
strive to be both open-minded and prudent in the integra-
tion of technology into treatment for first-episode psychosis.
Although many mental health apps are currently available,
the vast majority have not been scientifically evaluated.112,119
However, the literature on the use of apps for clinical treatment

of psychotic-spectrum disorders – despite being limited – does
provide strong evidence for the feasibility of this approach as
well as high rates of patient engagement and interaction.120
Conclusion
Outside of the first-episode psychosis literature, Guralnick121
has highlighted the distinction between first-generation and
second-generation research – research designed to investigate
the efficacy/effectiveness of an intervention versus research
designed to investigate how to optimize outcomes associated
with a proven intervention. With the efficacy and effective-
ness of numerous psychosocial interventions for first-episode
psychosis clearly established, scholars have noted the growing
need for a shift toward second-generation research within the
field.122 The optimization strategies described above highlight
some of the increasing corpus of second-generation research
on the treatment of first-episode psychosis that is emerging
internationally. Ultimately, such research has the potential to
optimize the treatment response to evidence-based psycho-

social interventions and to enhance the improved (but still
suboptimal) treatment outcomes commonly experienced
by individuals with first-episode psychosis. Moreover, as
interest in intervention for psychosis before the first-episode
grows,123,124 continued research on the optimization of psy-
chosocial interventions may also highlight ways to improve
the prevention of psychotic disorders among those at clinical
high risk.
Disclosure
Drs Breitborde and Moe have both received salary support
from the Institute for Mental Health Research (IMHR)
to support the launch of IMHR’s new clinical service for
individuals with first-episode psychosis. They also received
salary support from the Ohio Department of Mental Health
and Addiction Services to support the launch of a new
clinical service for individuals with first-episode psychosis
in Fairfield County, Ohio. This project was supported by
funds provided by The Ohio State University Department of

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Psychiatry and Mental Health to Dr Breitborde. The authors
report no other conflicts of interest in this work.
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