The Graduated Recovery Intervention Program for First Episode Psychosis: Treatment Development and Preliminary Data

  • Evan J. Waldheter
  • David L. Penn
  • Diana O. Perkins
  • Kim T. Mueser
  • Leanne Whaley Owens
  • Elizabeth Cook
Original Paper


The Graduated Recovery Intervention Program (GRIP) is a novel cognitive-behavioral therapy program designed to facilitate functional recovery in people who have experienced an initial episode of psychosis. In this paper, the treatment development process of GRIP is described and data from an open feasibility trial are presented. Findings suggest clinical and psychosocial benefits associated with GRIP, and the treatment was well-received by clients and therapists. The retention rate of 67%, however, suggests the need for protocol modifications to improve engagement. Initial data on the efficacy of GRIP are encouraging, although the study design precludes more robust conclusions at this time.


Psychosocial treatment Early psychosis Functional recovery 



The authors would like to thank the clients, clinicians, and researchers who have contributed to the development and evaluation of GRIP. We also acknowledge the assistance of Sarah Uzenoff, M.A., who conducted analyses on pilot data, Robert Hamer, Ph.D. and Abby Scheer for providing data management services, Johanna Boobas, LCSW, Abigail Judge, M.A., Brent Moos, LCSW, Jennifer Nieri, LCSW, and Lyse DeBourguignon, LCSW, for serving as GRIP therapists, Marianne Livingston, LCSW, for conducting study assessments, and Bebe Smith, LCSW and Sylvia Saade, Ph.D., for their administrative support at STEP and OASIS. Support for the development of GRIP has been provided by NIMH grant R34 1-MH071252-01A1 awarded to DLP.


  1. Addington, D., Addington, J., & Maticka-Tyndale, E. (1993). Assessing depression in schizophrenia: The Calgary Depression Scale. British Journal of Psychiatry, 163(Suppl. 22), 39–44.Google Scholar
  2. Addington, J., & Gleeson, J. (2005). Implementing cognitive-behavioural therapy for first-episode psychosis. British Journal of Psychiatry, 187(Suppl. 48), s72–s76.CrossRefGoogle Scholar
  3. Addington, J., Mansley, C., & Addington, D. (2003). Weight gain in first-episode psychosis. Canadian Journal of Psychiatry, 48, 272–276.Google Scholar
  4. Bassett, J., Lloyd, C., & Bassett, H. (2001). Work issues for young people with psychosis: Barriers to employment. The British Journal of Occupational Therapy, 64, 66–72.Google Scholar
  5. Beck, J. S. (1995). Cognitive therapy: Basics and beyond. New York: Guilford Press.Google Scholar
  6. Bellack, A. S. (2004). Skills training for people with severe mental illness. Psychiatric Rehabilitation Journal, 27, 375–391.PubMedCrossRefGoogle Scholar
  7. Bellack, A. S., & DiClemente, C. C. (1999). Treating substance abuse among patients with schizophrenia. Psychiatric Services, 50, 75–80.PubMedGoogle Scholar
  8. Bellack, A. S., Mueser, K. T., Gingerich, S., & Agresta, J. (2004). Social skills training for schizophrenia: A step-by-step guide (2nd ed.). New York: Guilford Press.Google Scholar
  9. Bertolote, J., & McGorry, P. D. (2005). Early intervention and recovery for young people with early psychosis: Consensus statement. British Journal of Psychiatry, 187(Suppl. 48), s116–s119.CrossRefGoogle Scholar
  10. Birchwood, M. (2003). Pathways to emotional dysfunction in first-episode psychosis. British Journal of Psychiatry, 182, 373–375.PubMedCrossRefGoogle Scholar
  11. Birchwood, M., Smith, J., Cochrane, R., Wetton, S., & Copestake, S. (1990). The Social Functioning Scale: The development and validation of a new scale of social adjustment for use in family intervention programmes with schizophrenic patients. British Journal of Psychiatry, 157, 853–859.PubMedCrossRefGoogle Scholar
  12. Birchwood, M., Todd, P., & Jackson, C. (1998). Early intervention in psychosis: The critical period hypothesis. British Journal of Psychiatry, 172(Suppl. 33), 53–59.Google Scholar
  13. Bradford, D. W., Perkins, D. O., & Lieberman, J. A. (2003). Pharmacological management of first-episode schizophrenia and related nonaffective psychoses. Drugs, 63, 2265–2283.PubMedCrossRefGoogle Scholar
  14. Carroll, K. M., & Nuro, K. F. (2002). One size cannot fit all: A stage model for psychotherapy manual development. Clinical Psychology: Science and Practice, 9, 396–406.CrossRefGoogle Scholar
  15. Chadwick, P., Birchwood, M., & Trower, P. (1996). Cognitive therapy for delusions, voices and paranoia. Chichester, England: John Wiley & Sons.Google Scholar
  16. Cohen, J. (1988). Statistical power analysis for the behavioral sciences. Hillsdale, NJ: Erlbaum.Google Scholar
  17. Dixon, L., McFarlane, W., Lefley, H., Lucksted, A., Cohen, M., Falloon, I. R. H., et al. (2001). Evidence-based practices for services to families of people with psychiatric disabilities. Psychiatric Services, 52, 903–910.PubMedCrossRefGoogle Scholar
  18. Dolder, C. R., Lacro, J. P., Warren, K. A., Golshan, S., Perkins, D. O., & Jeste, D. V. (2004). Brief Evaluation of Medication Influences and Beliefs: Development and testing of a brief scale for medication adherence. Journal of Clinical Psychopharmacology, 24, 404–409.PubMedCrossRefGoogle Scholar
  19. Drake, R. E., Mueser, K. T., Brunette, M. F., & McHugo, G. J. (2004). A review of treatments for people with severe mental illnesses and co-occurring substance use disorders. Psychiatric Rehabilitation Journal, 27, 360–374.PubMedCrossRefGoogle Scholar
  20. Drake, R. E., Mueser, K. T., & McHugo, G. J. (1996). Clinician rating scales: Alcohol Use Scale (AUS), Drug Use Scale (DUS), and Substance Abuse Treatment Scale (SATS). In L. I. Sederer & B. Dickey (Eds.), Outcomes assessment in clinical practice (pp. 113–116). Baltimore: Williams & Wilkins.Google Scholar
  21. Edwards, J., Hinton, M., Elkins, K., & Anthanasopoulos, O. (2003). Cannabis and first-episode psychosis: The CAP project. In H. Graham, K. T. Mueser, M. Birchwood, & A. Copello (Eds.), Substance misuse in psychosis: Approaches to treatment and service delivery (pp. 283–304). Chichester, England: John Wiley & Sons.Google Scholar
  22. Edwards, J., Maude, D., Herrman-Doig, T., Wong, L., Cocks, J., Burnett, P., et al. (2002). A service response to prolonged recovery in early psychosis. Psychiatric Services, 53, 1067–1069.PubMedCrossRefGoogle Scholar
  23. Edwards, J., Wade, D., Herrman-Doig, T., & Gee, D. (2004). Psychological treatment of persistent positive symptoms in young people with first-episode psychosis. In J. F. M. Gleeson & P. D. McGorry (Eds.), Psychological interventions in early psychosis: A treatment handbook (pp. 191–208). Chichester, England: John Wiley & Sons.Google Scholar
  24. EPPIC. (2001). Case management in early psychosis: A handbook. Melbourne, Australia: EPPIC.Google Scholar
  25. Falzer, P. R., Stayner, D. A., & Davidson, L. (2004). Principles and strategies for developing psychosocial treatments for negative symptoms in early course psychosis. In J. Gleeson & P. D. McGorry (Eds.), Psychological interventions in early psychosis: A treatment handbook (pp. 229–243). Chichester, England: John Wiley & Sons.Google Scholar
  26. First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. W. (1996). Structured Clinical Interview for DSM-IV Axis I Disorders—Patient edition (SCID-I/P, Version 2.0). New York: Biometrics Research Department.Google Scholar
  27. Fowler, D., Garety, P., & Kuipers, E. (1995). Cognitive behaviour therapy for people with psychosis. Chichester, England: John Wiley & Sons.Google Scholar
  28. Gaudiano, B. A. (2005). Cognitive behavior therapies for psychotic disorders: Current empirical status and future directions. Clinical Psychology: Science and Practice, 12, 33–50.CrossRefGoogle Scholar
  29. Grant, C., Addington, J., Addington, D., & Konnert, C. (2001). Social functioning in first- and multiepisode schizophrenia. Canadian Journal of Psychiatry, 46, 746–749.Google Scholar
  30. Green, A. I., Tohen, M. F., Hamer, R. M., Strakowski, S. M., Lieberman, J. A., Glick, I., et al. (2004). First episode schizophrenia-related psychosis and substance use disorders: Acute response to olanzapine and haloperidol. Schizophrenia Research, 66, 125–135.PubMedCrossRefGoogle Scholar
  31. Haddock, G., & Lewis, S. (2005). Psychological interventions in early psychosis. Schizophrenia Bulletin, 31, 697–704.PubMedCrossRefGoogle Scholar
  32. Haddock, G., Tarrier, N., Morrison, A. P., Hopkins, R., Drake, R., & Lewis, S. (1999). A pilot study evaluating the effectiveness of individual inpatient cognitive-behavioural therapy in early psychosis. Social Psychiatry and Psychiatric Epidemiology, 34, 254–258.PubMedCrossRefGoogle Scholar
  33. Hall, P. L., & Tarrier, N. (2003). The cognitive-behavioural treatment of low self-esteem in psychotic patients: A pilot study. Behaviour Research and Therapy, 41, 317–332.PubMedCrossRefGoogle Scholar
  34. Heinssen, R. K., Liberman, R. P., & Kopelowicz, A. (2000). Psychosocial skills training for schizophrenia: Lessons from the laboratory. Schizophrenia Bulletin, 26, 21–46.PubMedGoogle Scholar
  35. Hoffmann, H., & Kupper, Z. (2002). Facilitators of psychosocial recovery from schizophrenia. International Review of Psychiatry, 14, 293–302.CrossRefGoogle Scholar
  36. International Early Psychosis Association Writing Group. (2005). International clinical practice guidelines for early psychosis. British Journal of Psychiatry, 187(Suppl. 48), s120–s124.Google Scholar
  37. Jackson, H. J., McGorry, P. D., & Edwards, J. (2001a). Cognitively oriented psychotherapy for early psychosis: Theory, praxis, outcomes, and challenges. In P. W. Corrigan & D. L. Penn (Eds.), Social cognition and schizophrenia (pp. 249–284). Washington, DC: American Psychological Association.Google Scholar
  38. Jackson, H., McGorry, P. D., Edwards, J., Hulbert, C., Henry, L., Francey, S., et al. (1998). Cognitively-oriented psychotherapy for early psychosis (COPE): Preliminary results. British Journal of Psychiatry, 172(Suppl. 33), 93–100.Google Scholar
  39. Jackson, H., McGorry, P. D., Henry, L., Edwards, J., Hulbert, C., Harrigan, S. M., et al. (2001b). Cognitively oriented psychotherapy for early psychosis (COPE): A 1-year follow-up. British Journal of Clinical Psychology, 40, 57–70.PubMedCrossRefGoogle Scholar
  40. Jolley, S., Garety, P., Craig, T., Dunn, G., White, J., & Aitken, M. (2003). Cognitive therapy in early psychosis: A pilot randomized controlled trial. Behavioural and Cognitive Psychotherapy, 31, 473–478.CrossRefGoogle Scholar
  41. Judge, A. M., Perkins, D. O., Nieri, J., & Penn, D. L. (2005). Pathways to care in first episode psychosis: A pilot study on help-seeking precipitants and barriers to care. Journal of Mental Health, 14, 465–469.CrossRefGoogle Scholar
  42. Kay, S. R., Opler, L. A., & Fiszbein, A. (1992). Positive and Negative Syndrome Scale: Manual. Toronto: Multi-Health Systems.Google Scholar
  43. Kingdon, D., & Turkington, D. (2004). Cognitive therapy of schizophrenia. New York: Guilford Press.Google Scholar
  44. Kuipers, E., Garety, P., Fowler, D., Dunn, G., Bebbington, P., Freeman, D., et al. (1997). London-East Anglia randomised controlled trial of cognitive-behavioural therapy for psychosis, I. Effects of the treatment phase. British Journal of Psychiatry, 171, 319–327.PubMedCrossRefGoogle Scholar
  45. Lewis, S., Tarrier, N., & Drake, R. J. (2005). Integrating non-drug treatments in early schizophrenia. British Journal of Psychiatry, 187(Suppl. 48), s65–s71.CrossRefGoogle Scholar
  46. Lewis, S., Tarrier, N., Haddock, G., Bentall, R., Kinderman, P., Kingdon, D., et al. (2002). Randomised controlled trial of cognitive-behavioural therapy in early schizophrenia: Acute-phase outcomes. British Journal of Psychiatry, 181(Suppl. 43), s91–s97.CrossRefGoogle Scholar
  47. Liberman, R. P., Kopelowicz, A., Ventura, J., & Gutkind, D. (2002). Operational criteria and factors related to recovery from schizophrenia. International Review of Psychiatry, 14, 256–273.CrossRefGoogle Scholar
  48. Mayerhoff, D. I., Loebel, A. D., Alvir, J. M. J., Szymanski, S. R., Geisler, S. H., Borenstein, M., et al. (1994). The deficit state in first-episode schizophrenia. American Journal of Psychiatry, 151, 1417–1422.PubMedGoogle Scholar
  49. McGorry, P. D. (1992). The concept of recovery and secondary prevention in psychotic disorders. Australian and New Zealand Journal of Psychiatry, 26, 3–17.PubMedCrossRefGoogle Scholar
  50. McGorry, P. D. (2004). An overview of the background and scope for psychological interventions in early psychosis. In J. Gleeson & P. D. McGorry (Eds.), Psychological interventions in early psychosis: A treatment handbook (pp. 1–21). Chichester, England: John Wiley & Sons.Google Scholar
  51. Miller, W., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2nd ed.). New York: Guilford Press.Google Scholar
  52. Mintz, A. R., Addington, J., & Addington, D. (2004). Insight in early psychosis: A 1-year follow-up. Schizophrenia Research, 67, 213–217.PubMedCrossRefGoogle Scholar
  53. Mueser, K. T., Corrigan, P. W., Hilton, D. W., Tanzma, B., Schaub, A., Gingerich, S., et al. (2002). Illness management and recovery: A review of the research. Psychiatric Services, 53, 1272–1284.PubMedCrossRefGoogle Scholar
  54. Mueser, K. T., & Drake, R. E. (2005). How does a practice become evidence-based? In R. E. Drake, M. R. Merrens, & D. W. Lynde (Eds.), Evidence-based mental health practice: A textbook (1st ed., pp. 217–241). New York: W.W. Norton Company Ltd.Google Scholar
  55. Mueser, K. T., Meyer, P. S., Penn, D. L., Clancy, R., Clancy, D. M., & Salyers, M. P. (2006). The Illness Management and Recovery Program: Rationale, development, and preliminary findings. Schizophrenia Bulletin, 32(Suppl. 1), S32–S43.PubMedCrossRefGoogle Scholar
  56. Mueser, K. T., Noordsy, D., Drake, R. E., & Fox, L. (2003). Integrated treatment for dual disorders: A guide to effective practice. New York: Guilford Press.Google Scholar
  57. Noordsy, D., Torrey, W., Mueser, K. T., Mead, S., O’Keefe, C., & Fox, L. (2002). Recovery from severe mental illness: An intrapersonal and functional outcome definition. International Review of Psychiatry, 14, 318–326.CrossRefGoogle Scholar
  58. Norman, R. M. G., Lewis, S., & Marshall, M. (2005). Duration of untreated psychosis and its relationship to clinical outcome. British Journal of Psychiatry, 187(Suppl. 48), s19–s23.CrossRefGoogle Scholar
  59. Norman, R. M. G., Malla, A. K., & Manchanda, R. (2007). Is untreated psychosis socially toxic? Early Intervention in Psychiatry, 1, 267–270.CrossRefGoogle Scholar
  60. Penn, D. L., Waldheter, E. J., Perkins, D. O., Mueser, K. T., & Lieberman, J. A. (2005). Psychosocial treatment for first-episode psychosis: A research update. American Journal of Psychiatry, 162, 2220–2232.PubMedCrossRefGoogle Scholar
  61. Perkins, D. O. (1999). Adherence to antipsychotic medications. Journal of Clinical Psychiatry, 60(Suppl. 12), 25–30.PubMedGoogle Scholar
  62. Pilling, S., Bebbington, P., Kuipers, E., Garety, P., Geddes, J., Orbach, G., et al. (2002). Psychological treatments in schizophrenia. I. Meta-analysis of family intervention and cognitive behaviour therapy. Psychological Medicine, 32, 763–782.Google Scholar
  63. Power, P. (2004). Suicide prevention in early psychosis. In J. Gleeson & P. D. McGorry (Eds.), Psychological interventions in early psychosis: A treatment handbook (pp. 175–190). Chichester, England: John Wiley & Sons.Google Scholar
  64. Power, P., Bell, R. J., Mills, R., Herrman-Doig, T., Davern, M., Henry, L., et al. (2003). Suicide prevention in first episode psychosis: The development of a randomised controlled trial of cognitive therapy for acutely suicidal patients with early psychosis. Australian and New Zealand Journal of Psychiatry, 37, 414–420.PubMedCrossRefGoogle Scholar
  65. Robinson, D. G., Woerner, M. G., McMeniman, M., Mendelowitz, A., & Bilder, R. M. (2004). Symptomatic and functional recovery from a first episode of schizophrenia or schizoaffective disorder. American Journal of Psychiatry, 161, 473–479.PubMedCrossRefGoogle Scholar
  66. Rounsaville, B. J., Carroll, K. M., & Onken, L. S. (2001). A stage model of behavioral therapies research: Getting started and moving on from stage I. Clinical Psychology: Science and Practice, 8, 133–142.CrossRefGoogle Scholar
  67. Spaniol, L., Wewiorski, N. J., Gagne, C., & Anthony, W. A. (2002). The process of recovery from schizophrenia. International Review of Psychiatry, 14, 327–336.CrossRefGoogle Scholar
  68. Spencer, E., Birchwood, M., & McGovern, D. (2001). Management of first-episode psychosis. Advances in Psychiatric Treatment, 7, 133–142.CrossRefGoogle Scholar
  69. Tarrier, N. (2005). Cognitive-behaviour therapy for schizophrenia: A review of development, evidence, and implementation. Psychotherapy and Psychosomatics, 74, 136–144.PubMedCrossRefGoogle Scholar
  70. Tarrier, N., Beckett, R., Harwood, S., Baker, A., Yusupoff, L., & Ugarteburu, I. (1993). A trial of two cognitive-behavioural methods of treating drug-resistant residual psychotic symptoms in schizophrenic patients. I. Outcome. British Journal of Psychiatry, 162, 524–532.PubMedCrossRefGoogle Scholar
  71. Tarrier, N., Lewis, S., Haddock, G., Bentall, R., Drake, R., Kinderman, P., et al. (2004). Cognitive-behavioural therapy in first-episode and early schizophrenia: 18-month follow-up of a randomised controlled trial. British Journal of Psychiatry, 184, 231–239.PubMedCrossRefGoogle Scholar
  72. Tohen, M., Strakowski, S. M., Zarate, C., Jr., Hennen, J., Stoll, A. L., Suppes, T., et al. (2000). The McLean-Harvard first-episode project: 6-month symptomatic and functional outcome in affective and nonaffective psychoses. Biological Psychiatry, 48, 467–476.PubMedCrossRefGoogle Scholar
  73. Torrey, E. F. (1995). Surviving schizophrenia: A manual for families, consumers, and providers (3rd ed.). New York: Harper Perennial.Google Scholar
  74. Turkington, D., Kingdon, D., & Weiden, P. J. (2006). Cognitive behavior therapy for schizophrenia. American Journal of Psychiatry, 163, 365–373.PubMedCrossRefGoogle Scholar
  75. Westen, D. (2002). Manualizing manual development. Clinical Psychology: Science and Practice, 9, 416–418.CrossRefGoogle Scholar
  76. Whitehorn, D., Brown, J., Richard, J., Rui, Q., & Kopala, L. (2002). Multiple dimensions of recovery in early psychosis. International Review of Psychiatry, 14, 273–283.CrossRefGoogle Scholar
  77. Zimet, G. D., Powell, S. S., Farley, G. K., Werkman, S., & Berkoff, K. A. (1990). Psychometric characteristics of the Multidimensional Scale of Perceived Social Support. Journal of Personality Assessment, 55, 610–617.PubMedCrossRefGoogle Scholar
  78. Zygmunt, A., Olfson, M., Boyer, C. A., & Mechanic, D. (2002). Interventions to improve medication adherence in schizophrenia. American Journal of Psychiatry, 159, 1653–1664.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2008

Authors and Affiliations

  • Evan J. Waldheter
    • 1
  • David L. Penn
    • 1
  • Diana O. Perkins
    • 2
  • Kim T. Mueser
    • 3
  • Leanne Whaley Owens
    • 2
  • Elizabeth Cook
    • 2
  1. 1.Department of PsychologyUniversity of North Carolina at Chapel HillChapel Hill USA
  2. 2.Department of PsychiatryUniversity of North Carolina at Chapel HillChapel HillUSA
  3. 3.Dartmouth Medical SchoolHanover USA

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