EARLY DIAGNOSIS AND COUNSELING IN ADOLESCENTS WITH SUBCLINICAL PSYCHOTIC SYMPTOMS

Psychosis is a condition characterized on current diagnostic tests by impairment and may include severe disturbances of cognition, thinking, behaviour, and emotion. The need for early diagnosis and prevention of psychotic episodes in adolescents challenges traditional models of counselling, diagnosis, and treatment. The aim of the present study is to derive the main themes and psychological manifestations in the first psychotic episode in adolescents and to deepen knowledge and raise questions around the specific experiences of psychotic adolescents in order to help the clinical psychologist and psychotherapist in diagnostic and therapeutic counselling. This thus goes beyond the visible behaviour and the medical model that pays little attention to the causal relationships in psychosis and its unconscious components. Thirty-six adolescents (27 girls) with subclinical and clinical psychotic symptoms and 30 adolescents (16 girls) with neurotic symptoms were interviewed. A clinical approach was used - clinical psychological interview followed by psychotherapeutic work. Findings and statements can be found showing that early psychotic signs may change into a more severe adolescent crisis, as well as indications of the nature of anger towards parents, unstable mood and aggressivity. Leading themes in interviews and psychotherapeutic sessions may relate to feelings of insignificance in the world around them, unclear sexual identification, too close a relationship with their mothers, and anxiety about real or symbolic absence such as their mothers’ working away from home for long periods of time. In 79% of the interviews with adolescents with psychotic symptoms, we see a lack of real symbolic play in childhood. suitable for non-psychotic adolescents, in this case to change in the first psychotic episode.****What does this last sentence mean? The importance of early diagnosis is recognized and the known psychotherapeutic techniques must be used.


Introduction
The aim of the present study is to describe the specificities of hospitalized adolescents at different levels of functioning -neurotic and psychotic or presented in the sense of Kernberg's qualifications -in search of psychotherapeutic and counselling approaches for adolescents with more severe disorders, which is a complex process and requires a special therapeutic approach.Psychodynamic psychotherapy presupposes projective and introjective identifications of the adolescent with the therapist, which are different or even impossible in psychotic adolescents.
Early Onset Psychosis (EOP) is a more severe form of psychosis associated with a poorer prognosis.Psychological interventions are also considered to play an important role in the recovery plan.(Anagnostopoulou, 2019).At the same time, many clinical child psychologists have concerns when working with psychotic adolescents because of the need for special clinical experience and modification of psychotherapeutic and counselling methods.The purpose of this article is to outline the similarities and differences in early diagnosis, consultation, and therapeutic sessions for hospitalized adolescents with psychosis or concerns about psychosis as opposed to those adolescents with other disorders.This study focuses on the exchanges that occur during therapeutic discussions.
There are several studies on the effectiveness of different directions in psychotherapy (Browning 2013, James 2013, Thompson 2021, Obiols 2001).But the focus of this text is not on the promotion of one or another psychotherapy, but on the need for unification of the model of diagnostics and counselling, regardless of what additional psychotherapeutic counselling the therapist has to offer.In other words, we must shift the focus from the lack of models for working with psychotic patients, the paucity of data on such work in clinical conditions, and from the dispute about which modality of psychotherapy heals better.
The need to prevent psychotic episodes in adolescence requires a method of diagnosing subclinical symptoms.Such a method in a psychologist's clinical practice includes an interview and scales to examine subclinical psychotic symptoms in children and adolescents.
Much of the research has focused on family counselling (Rolli, 2021, Browning 2013, Calvo 2014), which has its basis in theoretical applications to the problem.
In the psychoanalytic tradition, Lacan's research relates the emergence of psychosis to the weakening of the paternal principle.The absence and the lack of the paternal principle lead to a low differentiation with the mother and to a pathological symbiosis in which the third is missing.(Lacan, 2008) The instruments for researching the risk of schizophrenia are not adapted to a Bulgarian sample, so the current study represents a pilot study with a clinical sample of Bulgarian According to McWilliams, 1999, the overriding principle of psychotherapy is to provide safety, security and support to the adolescents.Since they have violated the most important, basic sense of safety in the world, the setting must be unconditionally supportive with honest sharing, unconditional support, and respect for their ideas and opinions that they do not experience in communication with others outside of psychotherapy and these the adolescents will appreciate this.Caring for them is of the maternal type, not interpretations or work on the contents of mental disorders.The therapist openly explains that her or his way of working is emotional.

Methodology
Two groups of adolescents -the first: adolescents with psychotic symptoms (n = 36; 12-18 years) admitted to an inpatient psychiatric facility completed psychotherapy sessions, and the second, control group -non-psychotic inpatient adolescents with neurotic symptoms (n= 30; 12-18 years).
Adolescents are treated as inpatients, and another group attends sessions with a psychotherapist and a clinical psychologist in the form of a day ward.Psychotherapeutic sessions are conducted twice a week in the form of inpatient psychosomatic positive psychotherapy.The number of sessions varies depending on the stay in the hospital or in the day ward.
To distinguish the control group from the group with psychotic symptoms, a clinical-therapeutic primary survey of adolescents in diagnosis and therapy with concerns about psychosis and Schizotypal Personality Questionnaire-Child (SPQ-C)-Bulgarian version was used.For the control group to distinguish subclinical psychotic symptoms (M=12.10,SD =0.60 years).In order to test the equality hypothesis of the arithmetic mean between the factors of the SPQ, a Independentsamples t-test was performed.
Research interest in schizophyte has grown over the years in hopes of better understanding the etiology of schizophrenia − interpretative phenomenological analysis.− analysis of sentiment using lexical analysis.Quality data analysis is a descriptive method.It works with texts in the form of oral and written speech.In this analysis, it is of the utmost importance that the content of the text is entered conscientiously.

Results
Sample description 36 Psychotic Inpatient Adolescents (27 girls) and 30 adolescents with neurotic symptoms (16 girls) between the ages of 11 and 18 years were studied.
In a study using a Scale for the Assessment of Early Psychotic Signs with the Schizotypal Personality Questionnaire-Child (SPQ-C), the factor "Interpersonal Relationships" is reported to be dominant.The Schizotypal Personality Questionnaire (SPQ) is one of the most commonly used screening instruments for schizophyte in adults (Table 1 and Table 2) − Expressed disregard for paternal principle of laws and rules 86%.− Too close and undifferentiated relations with the mother 78%.− Language meaninglessness, described as emptiness, non-essentiality of the world 74%.In contrast, in the content analysis of the interviews of the adolescents with neurotic symptoms, themes such as: − order, rules, diligence in teaching (85%), -conflict between the desire for independence and the desire for*** 75%, problems in relationships with peers due to difficulty in relaxing and trusting their feelings, feeling not loved enough 80 %.

Discussion
The main differences between the control group and the group of adolescents with psychotic symptoms lie in the sense of acceptance of support and security, which is violated in psychotic adolescents and absent in those of the control group.The control group has an obsessive desire for conformity, rules, diligence in teaching (85%), combined with supervision over themselves.Aligned to an activity with many commitments, the adolescents of the control group have a problem in finding closeness, while the psychotic adolescents have the problem of isolation and fear of intrusion of others.Although they initially become close and there is a problem in the relationship between one another, in the control group there is a desire and ability for closeness, which in psychotic adolescents is replaced by the fear of the other and the desire for seclusion.In the psychotherapeutic transference, in adolescents with concerns about psychosis, the therapist feels a sense of threat, danger, coldness, like the edge of a rock that is missing in the conversations.The difference also lies in the stage of development of the family relationship.While the control group has the conflict between the desire for seclusion and the need for love and closeness, in the relationship of the psychotic adolescents there is a fusion, a symbiotic relationship, no distinction of the adolescent subject from the jealous parents As one of my patients said, "my mother thinks we are one person, she always speaks for us in the plural." So, the presented results lead us to some conclusions about the differences in working with adolescents with psychosis or concerns about it, with a leading anger towards parents, followed by an open disregard for the symbolic paternal principle, the law and the rules of social relations, combined with the fear of having their personal world invaded.The main difference is the strong feeling of lack of security, which is absent in the control group with neurotic anxiety.This points us to the need for a detailed study of the interaction between the psychotic teenager and his parents, so far obtained mainly for nervous cases, without which not much of the experience of the teenager with a psychotic disorder will remain useful and will be without consideration.Focusing on the teenager's interactions with his environment is important not only in neurotic cases, but also in psychotic teens.It is important for the therapist to stay away from any authoritarian attitudes of others, to be as sincere and open as any person willing to answer some personal questions, which would be unnecessary in the control group (McWilliams, 1999).
The least studied matter to date is the subsystem of factors in a psychotherapeutic model and its direct application during treatment.Study of The psychotherapeutic process will come to the forefront as we move forward with the traditional comparison of statistical measures of the patient's individual state before and after treatment.This will allow us to explore the processes with words in working with psychotic adolescents.(Guseva, 2002).
Of great importance for psychotherapy of psychotic disorders is the work of a group of researchers led by Bateson G., 2000.It is based on the theory of communication and the systems approach.They describe a particular form of family interaction called the situation "Double Blind" or " Bateson G. " and assume that it is an essential structural element of the traumatic experience that produces a schizophrenic response.The situation of "Double Blind" is characterized by a break in communication between people -in our case, between the parents or one of the parents and the child.In this way, two different, mutually exclusive messages and/or demands are communicated to the child.This results in the child not being able to get out of or clarify the situation (metacommunication prohibition).(Garrabe J., 2000; Ammon G., 1975).The main feature of this type of interaction in the family is the discrepancy between the verbal content of a communicative action and its emotional operation.Such a situation arises, for example, when the mother inwardly rejects her child The main goal of psychotherapy in psychosis is formulated as identity and the capacity for intimacy (a state opposed to isolation, the capacity for interpersonal relationships) and the integration of the ego.(Norcross, 2013).In most cases, the resolution of intrapsychic conflict formations leads to symptom relief, correction of the impaired ability to form loved ones, strong, long-term relationships.The ability to derive satisfaction from these relationships, the correction of relationships with others and the world at large is facilitated.Trust in others is greatly reduced and perceptions of the world as unreliable and dangerous correlate negatively with improved adjustment and resumption of functioning (Ming, 2002).
The home world of these adolescents is a reflection of what is going on in the family.In most cases, the family dynamic is expressed in a situation where the mother is unable to cope with the child's emotional experiences and the father is isolated or has a difficult relationship with the teen.The basis of their experience reveals the inability to bear the psychological pain of the absence of the object of the mother from whom they cannot separate.The success of psychotherapy depends on the ability to enable them to express their feelings.In the early stages, therapy serves as a "container," a place to express feelings and emotions.The elements of countertransference are particularly important in this process to understand the fears and hostility of the psychotic adolescent.According to Bion, the therapeutic work is expressed by the therapist taking the strong fears of the psychotic adolescent and creating conditions for the integration of the person based on an emotional development.(Bion, 1967(Bion, ,1999)).
From the point of view of positive psychotherapy, in the case of adolescents with psychotic symptoms, psychotherapy actually remains in the problematic moment of connection for a very long time because of the marked difficulties in this area.The psychotic subject, like the autistic person, tends to block out the presence of the therapist and, although formally present at the session, does not have basic bonding skills due to the terror of another person intruding into his inner world.it is the loneliness of the person who sees a meaningless and empty world, as if he had lost his values.Therefore, in the interactive phases of positive psychotherapy when working with psychotic adolescents, the emphasis is on the attachment phase and in fact this is the goal of therapy, attachment in a situation of perceived support and a sense of basic security.Of course, in the countertransference situation (Nancy, M), not every therapist is prepared to endure the "swallowing" and "eating" that the psychotic subject is capable of.The conflict response in these adolescents is ostensibly in the realm of contact, but in them contact with external reality is disrupted, and that with others is derivable from the lost connection with self.The symbiotic relationship with the mother is a common problem in these adolescents, in which their subjectivity is not built and is not recognized by the child's first significant caregiver.That is, we must work with the I-Thou relationship, which is less threatening than the I-We, with the clear indication that the therapist must abandon any authoritarian approach because of the danger of falling into the patient's transference, where the omniscient parent is from whom he is not yet differentiated.Such a danger requires the therapist to be much more open about his own life as a person, so as not to fall into the patient's fantasy and regulate the resulting sense of anxiety.
As for the basic skills that adolescents with psychotic symptoms exhibit, they are usually in the realm of fantasy, where we share a sense of heightened potential, mission and specialness, eccentricity and unusualness.
In positive psychotherapy, psychosis is seen as the ability to rethink one's life.This ability is evident in Veronika Ivanova conversations with psychotic adolescents when the silent, elusive adolescent suddenly becomes inspired and begins conversations about universal philosophical themes that are unproductive and lead to his deceptive belief that the world is indeed an empty and dangerous place where human connection is akin to ingestion and therefore both dangerous and desirableе (Messias, 2020).
The main differences in approach arise from the inner world of the adolescent, not so much from the reported symptoms, but from the way these adolescents perceive themselves and their place in contact with the other, from the terror they experience from the intrusion, and from the striving of the adolescents of the control group, to establish relationships in which they can defend themselves, relationships as equals, while in the psychotic group the therapist is put in the place of the great, the alldetermining parent, from whom he should be kept away if he does not want to jeopardize his contact with the psychotic adolescent.
It would be difficult to look for dependencies between the results of quantitative and qualitative analysis of the research without violating the scientific requirements of accuracy, but in the field of psychotherapy they have a reductionist character.The psychotherapist reports on the unique, delicate differences of the adolescent's affective life, on his controversies and his own experiences, which in working with psychotic adolescents can hardly*** This word means almost not at all.Do you mean easily?lead to a sense of confusion, ambiguity and chaos that actually comes close to the experience of the psychotic adolescent himself.A quantitative diagnosis by a psychotherapist with laittle clinical experience with psychotic subjects might wish to guard against misinterpretation of adolescent behavior as depressive, for example, based on the low level of affection in the outlet.Another common mistake is to interpret the silence of the psychotic adolescent as resistance related to a sense of impossibility to speak and a blockage for which he has no explanation.Such an interpretation can lead to unnecessary feelings of guilt and anxiety.

Conclusions
The conclusions of the present study relate to the need to work with process relationships in adolescents with subclinical signs of psychosis and psychotic adolescents.Psychotherapy with psychotic adolescents first requires clarification of the factors that contribute to psychotic adolescence in adolescence.There is a difference between the model of psychotherapy for troubled and neurotic adolescents and those with subclinical psychotic signs or psychosis.The need to change the familiar model for adolescents requires greater openness on the part of the therapist as a person, the creation of an environment that restores to the adolescent the lost sense of safety and security and unconditional support.Psychosis is not only a biological disease, the psychogenic moment, but the relationship to the degree of dysfunction in the family should also be considered in the pharmacological treatment of these adolescents.
. The results show that there is a statistically significant difference between the arithmetic scores of the two groups, the indicators of SPQ scales for both SIG.(2-talid) E 0.003 for the factor Cognitive Perception, 0.001 for Disorganization and 0.004 for Interpersonal.