MAPP Recovery Model

From the Couch to the Bus Depot to
the Mall to Work: Understanding the

Relationship of the Post-Psychotic
Adjustment Process to Recovery
Mary D. Moller
DNP, ARNP, APRN, PMHCNS-BC, CPRP, FAAN
Associate Professor,
Pacific Lutheran University
TEL: 203-737-1791
[email protected]
Faculty Disclosure
• Mary D. Moller, DNP, APRN, CPRP, FAAN is on the nurse
advisory panels for Alkermes and Otsuka Pharmaceuticals.
Disclosure
• The faculty have been informed of their responsibility to
disclose to the audience if they will be discussing off-label
or investigational use(s) of drugs, products, and/or devices
(any use not approved by the U.S. Food and Drug
Administration [FDA]).
• Applicable CME staff have no relationships to disclose
relating to the subject matter of this activity.
• This activity has been independently reviewed for balance.
Learning Objectives
• Examine the 4 phases and trajectory of the Milestones of
Adjustment Post-Psychosis (MAPP) Recovery Model
• Compare the clinical milestones and cognitive,
interpersonal, emotional, and physiological characteristics
associated with each of the 4 phases
• Assess implications of the MAPP Recovery Model for the
mental health system and day to day life of the person with
mental illnes and family
Primary Research Question
• What is the lived experience of persons with

schizophrenia in the postpsychotic adjustment
phase of recovery from psychosis?
Davidson’s (2003) Model of
Recovery from Schizophrenia
Davidson, L. (2003) Living outside mental illness:
Qualitative studies of recovery in schizophrenia. New
York: New York University Press.
Psychophenomenology of the
Postpsychotic Adjustment Process
Moller MD, et al. Arch Psychiatr Nurs. 2011;25(4):253-268.

Introduction to the MAPP
• Adjustment to psychosis is a multiphasic process that
takes 3 to 5 years
• Requires cognitive, emotional, interpersonal, and
physiological components
• Prerequisites to navigating the MAPP:
– Communication–both therapeutic and social
– Empathy
– Finding the right medication
– Encouragement
– Positive outlook
– Acceptance of diagnosis
– REQUIRES FAMILY SUPPORT
Secondary Questions
• How do individuals know if they have adjusted/not adjusted
to life after the diagnosis of schizophrenia?
• What are critical points in time postpsychosis that may
signal delay in postpsychotic adjustment?
• What factors delay the postpsychotic adjustment phase of
recovery from psychosis in patients with schizophrenia?
• What unmet mental healthcare needs contribute to delayed
postpsychotic adjustment?
• What aspects of treatment helped/hindered postpsychotic
adjustment?

Interview Questions
• What has your life been like since you had a psychotic
episode and were diagnosed with schizophrenia?
• Since having a psychotic episode and receiving a
diagnosis of schizophrenia, what does adjustment to life
mean to you? (this was modified to “What changes have
you had to make in your life because of schizophrenia?)
• Describe the points in time that have been important to you
in adjusting to life since your psychotic episode
• Was anything missing from your treatment that would have
helped in your adjustment to having a psychotic episode
and being diagnosed with schizophrenia?
• Is there anything else you would like to add?

Methodology
Psychophenomenology
Adrian van Kaam (1987)
Goal of Phenomenology
• “…to produce a description of a phenomenon of everyday
experience in order to understand it’s essential structure”
• Psychophenomenology places the emphasis on the
internal psychological world of a person by identifying the
necessary and essential constituents of the phenomenon
Priest H. Nurse Res. 2002;10(2):50-63.

Psychophenomenological Methodology
• 4 stages in 12 steps
– Analysis (Steps 1-8): Listing and preliminary groupings;
reduction; elimination
– Translation (Step 9): Hypothetical identification
– Transposition (Step 10): Application
– Phenomenological reflection (Steps 11-12): Final
identification
• Trustworthiness
• Involves intrasubjective, intersubjective, and experimental
validation reviewed by an independent panel of judges
van Kaam, A. (1987). Scientific formation. Formative spirituality. Vol. 4. New York: Crossroad
Publishing.
Initial Data Analysis of
542 Responses from 9 Participants
• Reduced to 7 potential constituents: #
• Symptoms and getting into treatment 84
• Response to symptoms 64
• Figuring it out 80
• What helped 174
• What didn’t help 59
• How I know I’m not adjusted 36
• How I’ll know when I am adjusted 45
• Eliminated symptom category as MAPP begins after
diagnosis

Reduction and Elimination
• Remaining 6 categories reduced to 4 constituents
• Recognition of the effect of psychotic symptoms on daily
functioning (cognitive dissonance)
• Gaining an understanding of the relation of symptoms to actual
reality (insight)
• Achieving stability in thinking and responding to others
(cognitive constancy)
• Performing age-appropriate ordinary activities of daily living as
others do (ordinariness)

Results
MAPP Recovery Model: Milestones of Adjustment
Postpsychosis
The Necessary and Essential Constituents
of Postpsychotic Adjustment: MAPP
• Recognizing emotional, interpersonal, cognitive, and
physiological states that indicate psychosis-induced cognitive
dissonance
• Gaining insight into the behavioral incongruences resulting from
psychosis-induced cognitive dissonance evident by emotional,
interpersonal, cognitive, and physiological outcomes
• Achieving cognitive constancy through a change in attitudes and
beliefs resulting in active engagement in emotional,
interpersonal, and cognitive, activities under the guidance of a
safe and successful treatment program
• Culminates in re-establishing ordinariness.

Cognitive Dissonance
Definition (Festinger, 1957)
• A state of being in which a person experiences conflict and
personal distress because of a perceived inconsistency
between 2 beliefs
• Typically 1 of the beliefs is known and the other is not
known or has not been experienced
• The discord between the beliefs results in behaviors that
are incongruent with previously held attitudes, values,
emotions, or beliefs
Festinger, L. (1957). A theory of cognitive dissonance. Evanston, IL: Stanford University Press.
Cognitive Dissonance:
Metaphor
• On the COUCH
– Spending time recognizing the effect of psychotic
symptoms on daily functioning
– This means the person has to first understand that
symptoms were psychosis and not reality
Moller, M.D. (2007). From the Couch to the Bus Depot to the Mall to Work. Podium Presentation:
Institute for Psychiatric Services, New Orleans, LA, October, 2007.
Summary
• Measurable outcomes
• Consistent reduction in psychotic symptoms resulting in
diminution of emotional, interpersonal, cognitive and
physiological states
• Dependent on:
– Pharmacologic efficacy
– Family support
• Duration: 6-12 months

Milestones of Achievement
Emotional Interpersonal
– Embarrassment – Hard to go out in public
– Fear – Hard to be around people
– Frustration
– Inability to handle stress
– Lost self-confidence
Cognitive Cognitive
– Confusion – Used drugs and alcohol
– Fear of saying something – Required too much energy
wrong

Insight:
Definition
• Recognition that illness symptoms are indeed pathological
and have created serious consequences in all aspects of
life
• Ability to understand the origin and progression of
symptoms
• Ability to internalize and verbalize the consequences of the
symptoms
• Overlays cognitive dissonance
Insight:
Metaphor
• At the Bus Depot
• Gaining an understanding of the relation of symptoms to
actual reality
• Experimenting with having symptoms and watching how
others respond when subjective symptoms occur
Insight:
Summary
• Measurable outcome
– Ability to master the process of conducting reliable reality
checks—“SORT IT OUT”
– Dependent on medication efficacy, family support, and
understanding treatment team
– Duration: 6 to 18 months

Insight:
Emotional Interpersonal
• Learning how to cope with • Communicate with others
life now
Cognitive Physical
• Trying to figure out own • Length of time to stabilize
thoughts from first episode
• Conducting own reality
checks
• Getting control of symptoms
• Recognize limitations
• Getting used to it

Cognitive Constancy:
Definition
• Change in attitude and beliefs about illness that result in
stabilizing the emotional, behavioral, and cognitive
incongruences of psychosis
• There is stability in all aspects of behavior based on reality-
based attitudes and beliefs
Metaphor
• Able to go to the mall
• Achieving stability in thinking and responding to others
• Forcing oneself to interact with others
Summary
• Measurable outcomes:
– Ability to muster the internal grit to begin re-engaging in age-
appropriate activities related to work and school
– Effectively re-engage in interpersonal relationships
• Dependent on:
– A positive initial treatment (FEP) experience
– Dependable support system
– Constructive use of time
– Medication efficacy
• Duration: 1-3 years
FEP = first episode psychosis.

Emotional Category
• Importance of having a positive initial hospital experience
• Dependable support system
• Something to do with my time
• Reassurance/encouragement
• Treatment environment that feels safe
• Not having too much quiet time
• Being around people
• Having hope

Milestones of Achievement (continued)
Cognitive Category
• Something to distract from the symptoms
• Accepting the need for treatment
• Learning I am not the only one with schizophrenia
• Getting back to what I used to do
• Think positive
• Being given choices

Interpersonal Category
• Have someone listen to me/understand me
• Someone to talk to about me
• Confidence in the counselor/therapist
• People need to be honest with reality
• Having people explain things
• Someone to talk to about general things
• Having help available when first get sick

Physical Category
• Right medication
• Taking care of the body
• Having a routine

Ordinariness:
Definition
• The ability to consistently and reliably engage in
and complete normal activities of daily living that
are reflective of prepsychosis functioning (but
not identical)

Ordinariness:
Metaphor
• Finally back to school or to WORK!
– Performing age appropriate activities of daily living as
others do
Ordinariness:
Summary
• Measurable outcome:
– Successfully enrolled in and completing a desired course of
study and/or
– Successfully sustaining employment for one year
• Dependent on:
– An absence of cognitive dissonance.
– Ability to complete age-appropriate activities related to work
and school
• Duration: 2+ years

Ordinariness:
Emotional
• Be able to think about the future
• Accomplish life goals
• Have my own place to live
Cognitive
• Manage symptoms
• Finish education
• Become employed
Interpersonal
• Do what other people do

Model of MAPP
MAPP Timeline
Achieve Life Cognitive
Goals Dissonance
Insight
Ordinariness Resume Life

Goals
Cognitive
Constancy
MAPP Recovery Model
Recovery and Treatment Milestones
Recovery Categories and
Treatment Milestones
• Each of the 4 constituents comprised of 3 or more
categories:
– Emotional
– Interpersonal
– Cognitive
– Physiological
• 50 different treatment milestones were identified

Breakdown of the 458 Responses
Into 50 Milestones
Category Milestones Responses
Emotional 17 159
Cognitive 16 135
Interpersonal 11 106
Physiological 6 58

Comparison of 50 Milestones by
Category and Phase
Cognitive Cognitive
Dissonance Insight Constancy Ordinariness
Emotional 5 1 8 3
Cognitive 2 5 6 3
Interpersonal 2 1 7 1
Physiological 2 1 3 0

Emotional Cognitive Interpersonal Physical

Embarrass- Hard to go Used drugs
Confusion
ment out in public and alcohol
Fear of saying Hard to be Required too
Fear
something wrong around people much energy
Frustration
Inability to
handle stress
Lost self-
confidence

Insight

Length of time to
Learning how to Trying to figure Communicate
stabilize from first
cope with life now out own thoughts with others
episode
Conducting own
reality checks
Getting control
of symptoms
Recognize
limitations
Getting used to it

Cognitive Constancy
Importance of having a Something to distract Have someone listen to Right medication
positive initial hospital from the symptoms me/understand me
experience
Dependable support Accepting the need Someone to talk Taking care of the body
system for treatment to about me
Something to do with Learning I’m not the Confidence in the Having a routine
my time only one with counselor/therapist
schizophrenia
Reassurance/ Getting back to what People need to be
encouragement I used to do honest with reality
Treatment environment Think positive Having people
that feels safe explain things
Not having too much Being given choices Someone to talk to
quiet time about general things
Being around people Having help available
when first get sick
Having hope

Ordinariness

Be able to think Manage symptoms Do what other
about the future people do
Accomplish life Finish education
goals
Have my own Become employed
place to live

Emotional Category: 17 Milestones
Cognitive Cognitive
Learning how Importance of having
Be able to think about
Embarrassment to cope a positive initial
the future
with life now hospital experience
Reassurance/
Fear encouragement Accomplish life goals
Treatment environment Have my own

Frustration
that feels safe place to live
Inability to Dependable support
handle stress system
Not having too much
Lost self-confidence
quiet time
Something to do
with my time
Being around people
Having hope

Cognitive Category: 16 Milestones
Cognitive Cognitive
Trying to figure out Something to distract Manage
Confusion
own thoughts from the symptoms symptoms
Fear of saying
Conducting own Accepting the
something Finish education
reality checks need for treatment
wrong
Learning I am not
Getting control Become
the only one
of symptoms employed
with schizophrenia
Recognize Getting back to what
limitations I used to do
Getting used to it Think positive
Being given choices

Interpersonal Category: 11 Milestones
Cognitive Cognitive
Hard to go out Communicate Have someone listen to Do what other
in public with others me/understand me people do
Hard to be Someone to talk
around people to about me
Confidence in the
counselor/therapist
People need to be honest
with reality
Having people
explain things
Someone to talk to about
general things
Having help available
when first get sick

Physiological Category: 6 Milestones
Cognitive Cognitive
Length of time to
Used drugs
stabilize from the Right medication
and alcohol
first episode
Required too Taking care of

much energy the body
Having a routine

Participant Comments
Implications for Clinical Treatment
Factors that Contribute to
• Extended duration of untreated psychosis
• Lack of access to specialized first-episode treatment
program
• Predominance of negative symptoms
• Poor response to medications
• Substance abuse
• Negative attitude of acute care staff
• Lack of staff patience

Consequences of Extended
• Can contribute to chronicity
• Delayed ability to achieve overall life goals
• Absence of realistic treatment plan
• Increased fear and anxiety
• Disrupted staff-individual interactions

Factors that Affect Ability to
Develop Insight
• Negative effect of societal stigma
• Negative family response to psychosis
• Unrealistic expectations for recovery
• Personal impact of psychotic episode
• Presence of anosgnosia
• Initial failure of illness cognition does not necessarily imply
anosgnosia

Factors that Affect Ability to
Develop Insight
• Paucity of reliable cognitive assessment
tools/interviews designed for schizophrenia
prevent individualized treatment based on
presenting cognitive deficits

Consequences of Inability to
Achieve Insight
• Presence of anosgnosia could impair/delay/prevent
attainment of insight resulting in the cycle of
crisis/relapse/rehospitalization
• Lack of attention to cognitive deficits impairs development
of the therapeutic relationship
• Disrupted family relationship

Consequences of Inability to
Achieve Insight (continued)
• Inability to master the skill of autonomous reality checks
• Increased direct and indirect costs of treatment
• Potential for homelessness
• Increased frustration of the individual, family, staff

Factors that Affect
Cognitive Constancy
• Change in attitudes and beliefs based on ability to
accurately perceive reality
• Presence of ongoing, unconditional support by family and
providers
• Need for encouragement and reassurance in order to trust
personal ability to reality check and increase willingness to
accurately understand psychosis-induced behaviors

Factors that Affect
Cognitive Constancy (continued)
• Need for sense of safety in housing and treatment to
develop self-confidence, self-esteem, and courage
• Competent, empathetic providers who instill trust by
informing the individual what is happening
• Psychoeducation regarding symptoms, medication,
diagnosis, treatment
• Observable and measurable skills that are Characteristics
are incorporated into treatment plan

Consequences of Delayed
Cognitive Constancy
• Confusion resulting from not understanding what is
happening
• Escalating fear caused by intensification of symptoms due
to being left alone
• Development of poor attitudes and negative self-beliefs
• Fear of both success and failure

Factors that Promote Ordinariness
• Careful consideration of prepsychosis life goals
• Courage to re-engage with previous goals
• Acquirement of age-appropriate skills (no maturational lag)
• Accurate evaluation and therapy for cognitive deficits
• Identify readiness to resume education/vocational training
• Availability of supported education, job coaching

Consequences of Delayed
Attainment of Ordinariness
• Increased relapse
• Poor ongoing symptom management
• Unemployment
• Absence of future orientation
• Unachieved life goals
• Unsuccessful in maintaining independent living
• Poor social skills
• Difficulty completing activities of daily living

Implications and Suggestions for
Policy and Program Design
Policy and Program Design
• Recovery from schizophrenia needs to be reframed as a
process
• Unrealistic expectations to re-engage with previously life
activities may be prematurely placed on the person in
recovery
• Policy makers need to be aware of the length of the
process of postpsychotic adjustment and the potential for
arrest in progression through the phases at any point

Policy and Program Design (continued)
• Particular attention should be paid to the phase of ‘getting
used to it’ and the individual process of accurately
determining reality
• Aggressive treatment in the acute phases of early
schizophrenia should be mandatory

• Recognition of an extended length of time in cognitive
dissonance or inability to achieve insight could promote
tolerance by programs who prematurely discharge
individuals who are ‘no shows’ or who have just
experienced an acute episode
• The capacity to assign financial burden to the four phases
of MAPP could redirect agency budgets in a manner
specifically tailored to the identified phases

• Social service agencies involved in housing who are aware
of MAPP may be more tolerant of problems related to
residents with schizophrenia
• Person-centered planning could utilize the results of this
study to change the predicted timeframe of interventions
such as cognitive behavioral therapy

• Treatment centers and programs must engage the family in
all aspects of treatment to facilitate movement of the
person with schizophrenia through the phases of MAPP
• The family needs to have support and respite in order to
provide the enduring support required by the person living
with schizophrenia

Hope for the Future
“We envision a future when everyone with mental

illness will recover, a future when mental illnesses
can be prevented or cured, a future when mental
illnesses are detected early, and a future when
anyone with a mental illness at any stage of life has
access to effective treatment and supports—
essentials for living, working, learning, and
participating fully in the community”
– The President’s New Freedom
Commission on Mental Illness
National Alliance on Mental Illness. President’s New Freedom Commission on Mental Illness.
http://www.nami.org/Content/NavigationMenu/Inform_Yourself/About_Public_Policy/New_Freedom
_Commission/Executive_Summary.htm. Accessed June 5, 2014.
“Take Aways”
• Distinguish factors that create a psychological/emotional
state of “being stuck” for patients living with psychotic
illnesses that severely limit the ability to move forward with
desired life goals
• Employ sensitivity to the development and timing of patient
goals and interventions that require interaction with the
public
• Formulate a recovery plan that incorporates emotional,
cognitive, interpersonal, and physiological milestones
based on the identified phases and characteristics of the
postpsychotic adjustment process
Moller, M.D. (2011, May). Grand Rounds, New York Presbyterian Hospital, Westchester, NY.

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From the Couch to the Bus Depot to

the Mall to Work: Understanding the

• What is the lived experience of persons with

Moller MD, et al. Arch Psychiatr Nurs. 2011;25(4):253-268.

Moller MD, et al. Arch Psychiatr Nurs. 2011;25(4):253-268.

Moller MD, et al. Arch Psychiatr Nurs. 2011;25(4):253-268.

Priest H. Nurse Res. 2002;10(2):50-63.

Moller MD, et al. Arch Psychiatr Nurs. 2011;25(4):253-268.

Moller MD, et al. Arch Psychiatr Nurs. 2011;25(4):253-268.

Moller MD, et al. Arch Psychiatr Nurs. 2011;25(4):253-268.

Moller MD, et al. Arch Psychiatr Nurs. 2011;25(4):253-268.

Moller MD, et al. Arch Psychiatr Nurs. 2011;25(4):253-268.

Moller MD, et al. Arch Psychiatr Nurs. 2011;25(4):253-268.

Moller MD, et al. Arch Psychiatr Nurs. 2011;25(4):253-268.

FEP = first episode psychosis.

Moller MD, et al. Arch Psychiatr Nurs. 2011;25(4):253-268.

Moller MD, et al. Arch Psychiatr Nurs. 2011;25(4):253-268.

Moller MD, et al. Arch Psychiatr Nurs. 2011;25(4):253-268.

Moller MD, et al. Arch Psychiatr Nurs. 2011;25(4):253-268.

Moller MD, et al. Arch Psychiatr Nurs. 2011;25(4):253-268.

Moller MD, et al. Arch Psychiatr Nurs. 2011;25(4):253-268.

Moller MD, et al. Arch Psychiatr Nurs. 2011;25(4):253-268.

Moller MD, et al. Arch Psychiatr Nurs. 2011;25(4):253-268.

Ordinariness Resume Life

Moller MD, et al. Arch Psychiatr Nurs. 2011;25(4):253-268.

Moller MD, et al. Arch Psychiatr Nurs. 2011;25(4):253-268.

Moller MD, et al. Arch Psychiatr Nurs. 2011;25(4):253-268.

Emotional Cognitive Interpersonal Physical

Moller MD, et al. Arch Psychiatr Nurs. 2011;25(4):253-268.

Emotional Cognitive Interpersonal Physical

Moller MD, et al. Arch Psychiatr Nurs. 2011;25(4):253-268.

Moller MD, et al. Arch Psychiatr Nurs. 2011;25(4):253-268.

Emotional Cognitive Interpersonal Physical

Moller MD, et al. Arch Psychiatr Nurs. 2011;25(4):253-268.

Treatment environment Have my own

Being around people

Moller MD, et al. Arch Psychiatr Nurs. 2011;25(4):253-268.

Moller MD, et al. Arch Psychiatr Nurs. 2011;25(4):253-268.

Moller MD, et al. Arch Psychiatr Nurs. 2011;25(4):253-268.

Required too Taking care of

Moller MD, et al. Arch Psychiatr Nurs. 2011;25(4):253-268.

Moller MD, et al. Arch Psychiatr Nurs. 2011;25(4):253-268.

Moller MD, et al. Arch Psychiatr Nurs. 2011;25(4):253-268.

Moller MD, et al. Arch Psychiatr Nurs. 2011;25(4):253-268.

Moller MD, et al. Arch Psychiatr Nurs. 2011;25(4):253-268.

Moller MD, et al. Arch Psychiatr Nurs. 2011;25(4):253-268.

Moller MD, et al. Arch Psychiatr Nurs. 2011;25(4):253-268.

Moller MD, et al. Arch Psychiatr Nurs. 2011;25(4):253-268.

Moller MD, et al. Arch Psychiatr Nurs. 2011;25(4):253-268.

Moller MD, et al. Arch Psychiatr Nurs. 2011;25(4):253-268.

Moller MD, et al. Arch Psychiatr Nurs. 2011;25(4):253-268.

Moller MD, et al. Arch Psychiatr Nurs. 2011;25(4):253-268.

Moller MD, et al. Arch Psychiatr Nurs. 2011;25(4):253-268.

Moller MD, et al. Arch Psychiatr Nurs. 2011;25(4):253-268.

Moller MD, et al. Arch Psychiatr Nurs. 2011;25(4):253-268.

Moller MD, et al. Arch Psychiatr Nurs. 2011;25(4):253-268.

Moller MD, et al. Arch Psychiatr Nurs. 2011;25(4):253-268.

“We envision a future when everyone with mental

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