First-Episode Psychosis
Aiden, 21, college junior
Fictional teaching case
Compare the formulations ↓Presentation
Three weeks of increasing paranoia: believes classmates are surveilling him, hears a voice commenting on his actions. Sleep disrupted. Grades dropping. Parents brought him in after he barricaded his dorm room. Says (intermittently coherent): 'They're watching everything I do. The voice tells me to be careful.'
Read the full case history and clinical context
No prior psychiatric history. Cannabis use (daily for 2 years, recently increased). Maternal uncle diagnosed with schizophrenia. Dean's list student until this semester. Parents describe him as 'always a bit of a loner but very bright.'
Compare how approaches understand this case
Two approaches to begin with; change them below. These are starting examples, not a clinical ranking.
Choose up to three approaches:
Showing 2 of 6 formulations.
CBTp
Normalizing framework: voice-hearing and unusual beliefs exist on a continuum. The paranoia reflects appraisals of threat that can be examined collaboratively. The voice is distressing because of the meaning Aiden assigns to it, not because it exists.
Gentle engagement, not challenging delusions directly. Normalizing voice-hearing. Examining evidence for beliefs collaboratively. Reducing distress associated with voices. Behavioral experiments.
"A lot of people hear voices at some point. More than you'd think. I'm curious about this one. What does it usually say? When is it loudest? When does it quiet down?"
Compassion-Focused Therapy
Threat system massively overactivated, soothing system offline. CFT does not claim to explain why the voice is there; it works on the relationship Aiden has with it, and that relationship is organised like a hostile social rank, with the voice dominant and Aiden subordinate. That is why 'be careful' arrives as a command rather than as a thought. Layered over it is shame: about hearing it at all, about the cannabis, about being the one his parents had to bring in. Shame keeps the threat system running.
Psychoeducation about threat system. Compassionate reframing of the experience: this is your brain trying to protect you, not you going crazy. Compassionate mind training. Reduce shame.
"Can I ask about something other than the voice for a minute. When your parents worked out what was going on, what did you feel about yourself? ... Ashamed. I want to come back to that word, because I think it is doing as much damage right now as the voice is."
IPNB
Stress, sleep loss and cannabis have overwhelmed the integrative capacity of a brain still developing at 21. Aiden is well outside his window of tolerance, and the systems that normally let experience be linked, sequenced and put into words are not doing it: what is left is raw threat signal with no narrative to hold it. IPNB describes a loss of integration here. It does not claim to explain where a hallucination comes from.
Co-regulation through attuned therapeutic presence. Gradually supporting neural integration through naming experience, building coherent narrative, reducing physiological stress.
"Your brain is overwhelmed right now. That makes sense given what you've been through. Let's slow everything down. Can you tell me about one thing that happened today that felt okay?"
Open Dialogue
The psychosis is a crisis of meaning within Aiden's social network: not solely a brain disease. The network (family, friends, university) needs to be mobilized immediately. Premature diagnosis and heavy medication may foreclose recovery.
Network meeting inside 24 hours: family, key friends, university support. Nothing about Aiden gets decided when Aiden is not in the room. The clinicians talk to each other about what they are hearing while everyone listens, which is Tom Andersen's reflecting practice put to work in the service of polyphony, the principle that several accounts stay in play and none is closed off. Tolerate the uncertainty rather than resolving it with a diagnosis. Minimise medication at the start.
"[To reflecting team, with Aiden and family present] I'm struck by how much fear is in this room: Aiden's fear, his parents' fear. I wonder if we can sit with that fear together before we rush to explain it."
Lacanian Psychoanalysis
Psychosis reflects foreclosure (Verwerfung) of the Name-of-the-Father: a structural position, not a disease. What was foreclosed from the symbolic returns in the real as hallucination and delusion. The triggering event likely involved a confrontation with paternal metaphor (authority, law, symbolic mandate).
The analyst becomes a 'secretary to the alienated': listening without interpreting, stabilizing through consistent presence, helping construct a supplementary symbolic framework (sinthome).
"[Extended silence, attentive listening] ... You said 'they're watching everything.' Who are they?"
Psychoanalysis
Read in the Freudian rather than the Lacanian line: libido has been withdrawn from the world and turned back on the ego, and the delusion is not the illness but the attempt at repair, a world rebuilt where the old one gave way. The persecutory content follows Freud's account of projection in the Schreber case, in which what cannot be borne inside is relocated outside and comes back as surveillance. Post-Kleinian writers describe the same collapse as a failure of containment, where states that cannot be thought get evacuated instead of held. Cannabis and university pressure are the load on the structure, not the structure.
Survive the contact and stay ordinary; reliability of frame does more early work than any interpretation. Interpret at the level of the anxiety and of what is happening in the room rather than the content of the delusion, so terror can be named as terror without the therapist being recruited into arbitrating what is real. The analyst's own dread is data: Fromm-Reichmann, Searles and Bion all treat what the clinician cannot bear to feel as part of what the patient could not contain. Long work, if Aiden stabilizes.
"I am not going to argue with you about whether they are watching. I am more interested in something else you said. Three weeks. What was happening three weeks ago?"
Where Approaches Genuinely Disagree
Do not argue with the belief and do not try to erase the voice. Work on the threat meaning attached to it, because the meaning is what makes it cost him something.
Treating this as one young man's appraisal has already conceded too much. Convene the family and the university inside 24 hours, hold the uncertainty, and let the meaning form in the room rather than in a formulation.
Philosophical Lenses
These are not treatment plans. They are ways of seeing — philosophical perspectives that illuminate aspects of this case that clinical modalities may not address directly.
Before deciding that Aiden's experience is pathological, ask what it is intelligible as. The paranoia may be a comprehensible response to a social environment that has become genuinely threatening: the surveillance, competition, and performance demands of college life. The voice commenting on his actions may express a divided self, a part of Aiden that has been observing and judging him long before it became audible. Laing would insist on understanding the content of the psychosis, not just its form. Barricading his room may be the act of someone desperately trying to protect a self that is fragmenting under unbearable pressure. The medical response, medication and containment, may be necessary, but it must not foreclose the meaning of the experience.
Foucault would ask: who decides that Aiden is psychotic? The institution (the university, the parents, the psychiatric apparatus) exercises the power to define his experience as illness. His barricading of his room can be read as resistance to institutional control as much as symptom. The 'treatment' he is about to receive will likely involve medication, surveillance, and the assignment of a psychiatric identity that will follow him through educational, employment, and insurance systems for the rest of his life. None of this means his suffering is not real. It means the system that responds to it is not neutral: it produces the categories through which the suffering becomes visible and manageable.
The moment Aiden enters the psychiatric system, he begins what Goffman calls a 'moral career': a trajectory of identity transformation imposed by a total institution. He will be stripped of his previous social identity (college student, son) and assigned a new one (psychiatric patient, first-episode psychosis). Staff will reinterpret his past behavior through this new lens: things that were previously unremarkable will become 'prodromal symptoms.' His resistance will be read as 'lack of insight.' His compliance will be read as 'progress.' The institution does not merely treat the illness; it produces the patient.
Sources & Method
This is a composite fictional case — no real client is depicted. Formulations represent how each modality would typically conceptualize and approach a case with this presentation, based on published clinical literature and training materials. Each formulation draws on the modality's own theoretical framework, key texts, and clinical principles as documented on its modality page. Full source citations for every modality are available on the Sources page.