Emerging psychosis risk in adolescence 
BACP University and College Counselling March 2026

Psychotic disorders, such as schizophrenia, are associated with complex, pervasive and chronic mental health issues and poor functioning. While pharmacological interventions have shown effectiveness in the management of acute symptoms, they appear less effective in addressing the functional disability and poor quality of life associated with psychotic conditions.

Of note, schizophrenia remains one of the world’s top 15 causes of disability, despite significant advances in assessment or diagnostic procedures, treatment practices and research methods.¹ Within this context, there is a growing interest in the application of psychotherapeutic approaches that can support functional recovery and better quality of life among people suffering from psychosis.

Importantly and of relevance to those working therapeutically with students, the period spanning from adolescence to young adulthood represents a critical developmental window where the first signs of psychosis typically emerge and become clinically relevant. This article discusses a number of issues relevant to the understanding and treatment of psychotic conditions, including: (1) the developmental continuum of psychosis expression; (2) risk factors associated with increased vulnerability to psychosis; (3) adolescence and young adulthood as critical periods of psychosis risk; (4) the relevance of early intervention; and (5) the clinical and empirical rationale for therapeutically targeting mentalizing dysfunctions in psychosis. 

The developmental continuum of psychosis expression 

Historically, the understanding and treatment of psychosis has been guided by a dichotomous categorical approach that clearly demarcates ‘normality’ from illness according to well-established symptomatic criteria, assessed primarily within the perceptual (hallucinations, delusions), affective (blunted affect, avolition, social withdrawal) and cognitive domains (disorganised thinking and behaviour). Although this categorical approach has proven clinically valuable in terms of informing diagnostic and treatment practices, due to its emphasis on people already suffering from psychotic disorders, its capacity to elucidate the dimensional and developmental nature of psychosis has remained limited. 

Indeed, according to more recent clinical conceptualisations and empirical research, psychotic experiences do not represent categorical entities, but are expressed along a continuum, ranging from mostly benign cognitive-perceptual aberrations (hallucination-like phenomena, suspiciousness or  paranoid ideation) and interpersonal difficulties (social anxiety, interpersonal distancing) to subclinical psychotic symptoms of lesser severity and duration, and finally to the severe reality distortions that typically mark the transition to a clinically diagnosable form of psychosis.² Within this contemporary model, core psychotic manifestations such as hallucinations and delusions are not seen as inherently tied to the clinical expression of psychosis, the latter being primarily determined by other symptom-related dimensions such as their frequency, duration and impact on day-to-day functioning. 

An important assumption guiding this dimensional continumbased understanding of psychosis is that psychotic phenomena are not only present in people diagnosed with psychotic disorders, but can also be observed among non-clinical individuals, albeit at an attenuated level. Indeed, while the lifetime prevalence rate of schizophrenia is reported at around 1%, large-scale population data suggest that psychotic phenomena are much more common in the general population, with reported prevalence rates for hallucination- and delusion-like experiences ranging from 10 to 28%.² 

Most interestingly perhaps, empirical research that has prospectively explored the long-term outcomes of individuals who report non-clinical, psychotic-like experiences suggests an increased risk of developing clinical psychosis, or an increase in the frequency and severity of these manifestations in subsequent years.³ This line of prospective research clearly designates a developmental dimension to psychosis, in which clinical symptoms are understood to be preceded by and emerge from more subtle non-clinical or subclinical manifestations. In essence, psychosis does not have a sudden onset, but rather emerges slowly over time across development. Therefore, understanding the core factors that may increase the risk of developing psychotic experiences, as well as the risk for transition from mostly benign manifestations to clinically relevant psychotic symptoms is key, both for the understanding and timely treatment of psychosis. 

Risk factors associated with the development of psychosis 

Psychosis is an extremely complex mental health condition that is causally associated with a multiplicity of genetic influences and environmental risk factors. For instance, children with a parent diagnosed with a psychotic disorder are shown to be at increased risk for developing psychosis themselves in the future, even if they were separated from this parent at birth, suggesting a strong genetic component.⁴ Beyond genetics, empirical research suggests that a number of factors linked with the social environment, such as early attachment adversity (i.e. childhood abuse and neglect), stressful life events (i.e. bereavement), living in urban or inner city environments, being a migrant or the child of a migrant (especially from a developing country), and cannabis use are all associated with increased risk for the development of psychosis.⁵ 

Yet, the vast majority of people who have experienced early childhood adversity, or live in an urban environment, have migrated from a developing country or use cannabis will never develop psychosis. Similarly, many people with a history of psychosis in their families will not develop psychosis. As such, the development of psychosis cannot be causally attributed to either genetic or environmental influences acting in isolation. Rather, it appears that psychosis emerges through the interaction of an underlying genetic predisposition with exposure to a multitude of risk-inducing environmental/social factors across development, together augmenting vulnerability for clinical illness. 

Adolescence and young adulthood as critical periods of psychosis risk 

Importantly, and of specific relevance to those working therapeutically with students, the first non-clinical manifestations of psychosis typically manifest during adolescence and tend to become clinically relevant towards young adulthood, with the peak age of onset for psychotic disorders identified as being between 18 to 25 years of age.⁶ Thus, the period spanning from adolescence to young adulthood appears to be a critical developmental window during which the first non-clinical and clinical signs of psychosis expression commonly emerge. 

The American psychologist Stanley Hall famously coined the term ‘storm and stress’ to characterise the emotionally turbulent nature of adolescent development. Indeed, the transition towards adolescence and young adulthood typically comes with a range of changes and novel experiences across the biological, psychological and social domains that are prone to generate emotional turmoil and stress. These include, among others, bodily and hormonal changes, new academic pressures at school or university, a decreasing dependence on family systems along with an increasing reliance on peer relationships, navigating autonomy and identity formation, as well as the initiation of romantic and sexual relationships. One can imagine the experience of a young person who moves away from their family home for the first time to attend university in another city or country. In addition to new academic anxieties, they may feel very lonely and homesick, scared about being in an unfamiliar environment, anxious about making new friends and adapting to their new life away from home. Similarly, a young person may feel devastated by experiencing rejection by a romantic partner for the first time in their life, or feel humiliated, terribly hurt and enraged by a negative remark made by a peer in a social situation. Fortunately, most adolescents and young adults will manage to face these challenges by regulating the emotional upheaval they may cause, and in turn use their developing experiences and close relationships to develop a more coherent sense of themselves. 

However, young people who are at genetic risk for psychosis, and have also experienced adverse and often deeply painful circumstances in their lives, may feel overwhelmed by and struggle to cope with the additional emotional demands that adolescence and young adulthood bring. Instead, they may resort to maladaptive coping strategies, such as mentally isolating into themselves and away from shared reality with others, in order to manage the distress associated with overwhelming emotional experiences. Critically however, these coping strategies may exacerbate psychosis expression, further increase social avoidance and lead to clinically relevant presentations. This is in line with research into the first-person experience of people suffering from psychosis, which suggests that the period preceding the transition to clinically relevant symptomatology during adolescence and young adulthood is characterised by experiences of interpersonal sensitivity, social anxiety, social discrimination, loneliness and isolation.⁷ 

The critical point I want to emphasise here is that while psychotic conditions are often considered as primarily cognitive or perceptual in nature, mainly due to their core symptomatic manifestations, the underlying lived experience appears to relate more to states of overwhelming affect. In other words, the perceptual aberrations, interpersonal distancing, as well as rigid and sometimes delusional thinking patterns observed in emerging psychosis, may characterise states where the individual is attempting to cope with an underlying emotional disturbance. This is clinically relevant, as a more robust capacity to regulate those strong emotional states may sustain adaptive interpersonal contact, prevent the progression of emerging psychosis and promote recovery among young people who are at increased risk. 

The relevance of early intervention in psychosis 

The increasing recognition of psychosis as a developmental disorder has led to a shifting emphasis towards an early intervention approach, aiming to identify and treat emerging psychosis during its earliest stages of expression, prior to transition to clinically diagnosable presentations. This is critical given that the transition to clinical psychosis is associated with pervasive impairments in social, interpersonal and occupational functioning that often persist despite symptomatic improvement following treatment. For instance, qualitative research suggests that individuals suffering from psychosis often report chronic forms of self-alienation, loss of personal meaning and lack of social connectedness, despite symptomatic improvement following pharmacological or brief psychological interventions.⁸ Similarly, quantitative studies suggest that up to 50% of adults suffering from clinical psychosis never recover their premorbid level of social functioning, despite symptomatic improvement.⁹

The relevance of intervening early is further underscored by studies showing that the duration of untreated psychosis is directly associated with higher levels of functional impairment and worse treatment outcomes, while early treatment has been shown to support both clinical and functional recovery.¹⁰ Given the relevance of early intervention, contemporary research in psychosis has sought to identify psychological factors that should be therapeutically targeted early to attenuate the progression of emerging psychosis at its earliest stages. 

Mentalizing as an early intervention treatment target in psychosis 

A key psychological function that appears to modulate the development of psychosis across its continuum of expression is mentalizing – the capacity to perceive, reflect on and interpret the intentional mental states, such as thoughts and feelings, that drive one’s own and others’ behaviours.¹¹ Mentalizing is a complex multidimensional construct that encompasses a number of higher order cognitive processes involved in mental state understanding, including theory of mind (inferring thoughts or feelings from others’ behaviours), empathy (understanding and relating to the emotional states of others), mindfulness (emotional self-awareness) and metacognition (cognitive self-awareness). Together, these psychological functions help us form representational models of human behaviour and inner experience in order to navigate the complexity of social interactions, as well as make sense of and regulate our own thinking and feeling states.

It is important to note that mentalizing is a developmental achievement that is originally acquired in early childhood through having one’s own states of mind understood and mirrored by caregivers in the context of secure attachment relationships. In contrast, experiences of early attachment adversity, such as childhood trauma and neglect have been prospectively associated with mentalizing difficulties later on in life.¹¹ 

Given that mentalizing contributes to sustaining continuity in one’s relationship to oneself, as well as continuity in close interpersonal relationships, it is considered critical for mental health. Conversely, mentalizing dysfunctions have been implicated in a range of mental health disorders, including psychosis. Indeed, from a clinical standpoint, most core psychotic symptoms explicitly entail a distorted understanding of one’s own or other peoples’ mental states. For instance, auditory hallucinations have been linked to the misattribution of one’s own inner voice or thoughts to external sources. Paranoid or persecutory delusions involve overattributing malevolent intentions to other people, while symptoms such as blunted affect may reflect difficulties in using affective tone and facial expressions to convey one’s inner states to other people. Furthermore, from an empirical standpoint, studies using interview assessments, self-report questionnaires and experimental methodologies to assess mentalizing abilities have consistently found that people suffering from psychosis show serious difficulties across different mentalizing domains, and these are associated with symptomatic severity as well as with the level of social functioning impairment.¹² 

Importantly, another line of research suggests that mentalizing difficulties are not only present in adults suffering with clinical psychosis, but are also observed in young people who report pre-clinical manifestations and are at increased risk for psychosis.¹³ Most interestingly and of relevance to early intervention, these studies further highlight that mentalizing may be a key factor that moderates the progression of emerging psychosis. For example, worse mentalizing abilities have been shown to predict transition to clinical psychosis among young adults who exhibit subclinical manifestations.¹⁴ On the other hand, better mentalizing abilities have been shown to support functional recovery among adolescents experiencing a first episode of psychosis.¹⁵ Similarly, better mentalizing abilities among young people who report non-clinical auditory hallucinations have been associated with a reduced likelihood of developing secondary delusional ideation.¹⁶ This line of empirical evidence suggests that the capacity to engage in reflective processes about one’s own and others’ thoughts and feelings may represent a resilience factor that protects at-risk young people against the effects of emerging psychosis. 

In accordance with these findings, our own research with non-clinical adolescents has shown that mentalizing abilities significantly moderate the link between non-clinical psychotic experiences and more serious perceptual and cognitive disturbances.^17,18 In other words, mentalizing appears to be a factor that may, at least in part, potentiate or protect against the progression of emerging psychosis towards clinically relevant symptoms. Overall, research seems to confirm the assumption that mentalizing plays an important role in determining early trajectories of emerging psychosis and may be a worthwhile treatment target in the context of early intervention. 

Therapeutically targeting mentalizing in early intervention for psychosis 

Mentalization based treatment (MBT) is a psychodynamically oriented form of psychotherapy originally developed for the treatment of borderline personality disorder. In recent years, applications of MBT for individuals suffering with psychosis and young people at risk for psychosis have been developed and empirically evaluated.¹⁹ Rather than focusing on symptom reduction, these treatment frameworks place emphasis on supporting young people to strengthen/ develop their mentalizing abilities, which can in turn help them regulate their felt experience, sustain a more coherent sense of self and remain engaged in adaptive interpersonal contact.²⁰ 

While a detailed discussion of specific therapeutic techniques is beyond the scope of this article, some of the basic components include: (1) the therapist adopting a ‘not-knowing stance’ that conveys curiosity about how the young person’s mind works; (2) inquiring about, labelling and helping the young person verbalise the inner states that may underlie their behaviours and symptoms, rather than focusing on behaviours and symptoms themselves; (3) sensitively challenging the young person’s rigid states of mind and offering alternative perspectives on their complex experiences; and (4) using the therapeutic relationship to support the young person to reflect on their inner states in the here and now of their experience with the therapist. In essence, MBT works by establishing an attachment relationship with the client and then continuously engaging them in a reflective process about any thoughts and feelings that emerge within this relationship. It is also important to note that within this treatment framework, mentalizing dysfunctions and also psychotic symptoms are not viewed as ‘impairments’, but rather as the young person’s means to reduce complexity in order to cope with overwhelming emotional and interpersonal experiences. 

More implicitly perhaps, the aim of therapy is to foster in the young person faced with emerging psychosis a sense of trust in the minds of others, but also their own mind, which can help them navigate and cope with complex emotional experiences. Instilling a sense of trust in others is particularly important given that in the context of serious early attachment adversity, or paranoid ideation, young people who are at risk for psychosis may approach experiences of relational intimacy, including the therapeutic encounter, with a hypervigilant and mistrustful attitude.²¹ To this end, it is critical to carefully regulate emotional arousal within the therapeutic relationship by staying with and validating the young person’s life experiences and current suffering, while also not triggering overwhelming emotional states that may increase hypervigilance and mistrust. Another critical point is to support the young person to begin trusting their own mind again, as people who have experienced or are still experiencing psychotic symptoms can become terrified of what their minds can do. This is where helping the young person to increase their capacity to relate to their own thoughts and feelings, to get a better sense of their mind, is of the utmost importance. Empirical evidence highlights the potential effectiveness of mentalization-oriented frameworks to the treatment of psychosis. For instance, randomised controlled trial data suggest that MBT is effective in supporting better social functioning for adults suffering with psychosis, with better outcomes for those with a recent psychosis onset compared to those with longer psychosis duration, again signifying the relevance of early intervention.²² Furthermore, recent outcome data from an MBT intervention with young people on the psychosis spectrum, who had previously refused to engage with other forms of treatment, showed significant treatment engagement and clinically relevant improvements across symptomatic and functional domains (i.e. school re-engagement) after 12 months of treatment.²¹ 

Even when MBT is not applied as a treatment modality in its own right, counsellors and psychotherapists working with adolescents and young adults faced with emerging psychosis can use the affect-based framework offered by MBT in their attempts to understand what these young people are going through, and help them understand something about how their own minds work. These attempts can often bring meaningful therapeutic outcomes as they convey to young people a strong sense of being in other peoples’ minds.