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CBT for Psychosis (Psychological Approaches to Psychosis (Vielwing…
CBT for Psychosis
What is Psychosis?
- Umbrella term – might have diagnosis of schizophrenia, bipolar disorder, delusional disorder, psychotic depression
- Perceive or interpret events differently – e.g., hallucinations, delusions, or flight of ideas
- Affects ~ 3% (underestimate), more common in urban areas
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Core elements of CBT
(Morrison and Barratt, 2010)
- Need an explicit, collaborative goal (the goal the patient themselves want to achieve)
- Engagement and therapeutic style (need to go in with a "productive style", e.g. making them feel as if you belief in them, that you understand them)
- Normalisation
- Individualised formulation based on cognitive model
- Appraisal and behaviour targeted for change (what the patient sees as causing the symptoms)
- Change occurs through new learning (facilitated through monitoring, guided discovery, testing out)
- Strategies for change implemented both within and outside sessions
- Aim to reduce distress and improve quality of life
Stages of CBT for psychosis
(Fowler, Garety and Kuipers, 1995)
- Engagement
- Assessmet and formulation
- Intervening with delusions and hallucinations
- Targeting low self-esteem, depression, anxiety and social lfunctioning
- Planning relapse reduction strategies and agreeing long-term goals and strategies t oreduce social disability
Engagement
Potential problems with engagement
- Voices - talking about therapist, telling client not to talk
- paranoia - about sessions/therapist
- thought disorder
- concentration and/or memory problems
- poor attendance at sessions
- sessions too stimulating/confusing/aversive
- difference of views
- client thinks therapist believes them to be mad/foolish
- worries about being admitted
- not wanting to talk about past experiences
- client feeling challenged and not listened to
Therapy Style 1
- A good therapeutic relationship is absolutely crucial, and all work with delusions must be done within context of therapeutic relationship:
- General: empathy, warmth, genuineness, listening skills (can be more difficult than you think)
- Need to be sensitive to:
- mental state (apologise about yet another assessment, ask re taking notes, check if hallucinating, be aware of fluctuations)
- Need to make sure the patient understands why we need certain information, because it might not be obvious to them (some information we don’t necessarily need, so leave it)
- beliefs about therapist
- expectations (client’s and your own)
Therapy style 2
- Need to be flexible with:
- structure and length of assessment
- contact (length of sessions, frequency)
- Need to be mindful about the patient’s capabilities, of e.g. how long can they manage a session for
- therapy demands (e.g. homework's, self-generated alternatives etc)
- style (from concrete to philosophical) depending on client
- To facilitate engagement:
- empathise whenever possible
- normalise whenever possible
- use of humour if appropriate
- may need to give specific reassurances
- honesty (about yourself, role within team, what you can offer)
- agree goals
- Can’t just expect that they will develop a therapeutic relationship with you (because of the nature of their illness), need to do everything we can to make the person feel that they can trust us, and that it is safe to talk to us. Often need to be very honest about yourself. Also need to make the conversation an enjoyable one (not just hard work)
Therapy style 3
- To facilitate assessment:
- ‘Columbo’ technique (e.g. “im not quite following you there, can you help me understand?”)
- be open-minded and interested
- Take patient seriously no matter what they say, this might be very hard to do sometimes, because some of the things they say seem so unexpected (have to think about, that at a brain level, these experiences are real for these patients, they receive them as e.g. real voices)
- take client seriously (regardless of content)
- see client as reasonable, struggling to understand difficult experiences
- take non-committal stance if necessary (- If a patient askes you “do you belief me”. Than you sometimes have to take a bit of a non-commital stand. E.g. saying “I can’t hear it myself, I can’t know, I’m not inside your shows, I don’t know what your neighbours intentions are, because I don’t know them. But it sounds that what you are experiencing is so real, that that’s the only way that you can make sense of it at the moment)
- persevere (keep going even if confused/overwhelmed, or therapy looks unlikely, or client hostile etc.)
Therapy style 4
- To facilitate intervention:
- need creativity
- Don’t be confrontational. Reassure the patient that you want to work with them, that you want to work together to tackle this problem
- be gentle (be prepared to back off)
- engage with what is distressing, not what is abnormal
- collaborative, not confrontational
- containment (don’t overarouse/elicit too much emotions, leave things till later) • agree to differ (but your version not necessarily right)
- Be contained, in the way of only addressing issues at the time that we are able to manage (because e.g. over-arousement makes someone with psychosis experiencing their symptoms even more) – keeping emotional temperature cool
Assessment
- There are no clear-cut distinctions between engagement, assessment, and intervention, but you can expect to spend up to 6 sessions or so dealing just with engagement and assessment issues.
- Current subjective problem & goals
- Most widely used symptom measure: PSYRATS (Haddock et. Al., 1999)
Assessing Delusions
- Current subjective problem & goals
- Onset – vulnerability factors and triggers, life events
- Changes over time – including better times and relapses
- Conviction, preoccupation, distress
- Day to day examples
- Triggers and consequences (ABCs)
- Maintenance factors (including other psychotic symptoms, emotions, safety behaviours, environment, drug and alcohol abuse)
- Protective factors
- View of self without delusions e.g. not special
- Who wants the belief to change and what would life be like for the client if it changed?
- What alternative beliefs might be available to the client and why might they have rejected them? e. g. being persecuted may be better than being mad
- develop hierarchy of distressing beliefs (if necessary)
Assessing Voices
Phenomenology
- Content (verbatim, if possible)
- Is it one word, a few words or a sentence?
- Is the content abusive, critical or funny?
- Do they talk to you? About you? Tell you to do things?
- Topography
- Frequency & length: How often? How long do they last?
- Audibility: How loud?
- Clarity: How clear?
- Locus: Where do they come from?
- How many?
- Language spoken? Gender? Age?
- Do they recognise the voice ?
Triggers
- Emotional states (e.g. shame, guilt, anxiety, depression, sadness)
- Social isolation and loneliness
- Lack of activity
BeliefsKey beliefs to assess are those aboutt:
- Omnipotence & omniscience (perceived power & knowledge base. Also compliance beliefs)
- How powerful is the voice?
- What will happen if the client ignores/disobeys the voice
- Purpose (Malevolence & benevolence)
- Do they believe the voice is intent on doing them harm/evil
- Identity
- does the client know the identity of the voices?
- Controllability and anger
- How much conrol (if any) do they believe they have over the voices?
- Content, presence and meaning
- What sense do they make of the content of the voice and its presence?
- What does it mean abou the client, other people and the world?
- Assessing the type of relationship
- style of interacter between patient and voice
- Beliefs about causes, coping (including medication), social networks, activities and support
- How does the client explain the process by which they are able to hear the voices?
- Are there any helpful/pleasant aspects of voices?
Not all just about voices
- Altough auditory hallucinations are most common, halluninations can occur in all other modalities
Beliefs and Voices: ConsequencesWhat impact do they have on theri life?
- Behavioural:
- Safety behaviours
- Engagement, compliance, threat mitigation, resistance
- Coping strategies
- Emotional
Person specific:
- Cognitive deficits
- Medication
Drug and alcohol use
- Other psychotic symptoms – thought disorder, negative symptoms etc
- Personal beliefs (religion)
- Relationship with services
- Social support and social relationships
- Short and long-term goals and plans
- Core-beliefs, ‘rules for living’ and schemas (sometimes)
- Life history (sometimes)
Secondary disturbances:
- Other emotional problems (low mood, anxiety, worry, intrusive thoughts, etc.)
- Cognitive distortions (as in found in anxiety and depression)
Look out for:
- Reaction to hypothetical disconfirmation & cognitive flexibility (flexibility indicates greater openness to consider alternatives)
- Can look out for maintenance cycles. E.g. delusional beliefs, that are maintained because of e.g. safety behaviours. Or e.g. the patient starts arguing a lot with collegues, complaining about them .. and this creating more problems, which then confirms their beliefs
- Emotional impact. What do they feel when they are in this situation. But also what emotions do they feel before (potential triggers)
- Match : the patients language. E.g. asking, when do you hear your neighbours shouting at you, instead of asking, when do you hear the voices (unless the patient calls them voices)
Formulation
Moving on from assessment
- Aim of assessment is to build up formulation
- Formulation need not challenge beliefs (e.g. impact of mood on voices; of worry and avoidance on persecutory ideation)
- Emphasise mechanism in order to focus on change
- Can gradually build more complex formulations if appropriate
- Coping work alongside assessment work (can use to access new appraisals – meaning of coping)
- What mechanisms are maintaining distress
- Looking for what people do in the short-term, that may make it worse in the long-term
- Possibly include coping strategies
- why are these things so distressing, and pre-occupying?
- Don't necessarily be contradicting what the patient presents
- Starts out very simple, builds up more if necessary (over time). Sometimes having a simplified version within sessions, and a more complex one for yourself
Intervention
Goals:
- Assess consequences of belief change carefully (eg grandiose delusions: meaning of life without belief/secondary gains? )
- Do not push for change
- Aim for distress, preoccupation/interference over conviction
- Aim for evidence for belief rather than belief itself
- Work with hierarchies
- Focus on maintaining cycles
Early on:
- Timeline (sometimes)
- Psychoeducation (stress-vulnerability model, cognitive model, information processing)
- Normalisation (continuum of experiences, of cognitive biases)
- Problem-solving
- Coping strategy enhancement
Proceed to:
- Sharing formulations
- Reality-checking & behavioural experiments
- Reframing (of illness model, of day to day events, of past events, of beliefs)
- Behavioural techniques (eg graded exposure, distraction, relaxation, coping cards, etc.)
- Cognitive techniques (eg Socratic questioning, adapting NAT thought records, alternative explanations (be prepared to float alternatives), decatastrophise, etc.)
General points:
- Work within client’s model of understanding
- May need to work within delusion
- Therapy often crab-like (e.g. targeting anxiety may impact on delusion without addressing delusions directly)
- May need to work on maintaining processes (e.g reasoning biases) rather than content of delusions
- Do not underestimate power of psychotic experiences
- Coping strategy enhancement
- Understanding negative cycle and triggers
- Working with beliefs – power, control, omniscience, identity, meaning & purpose, positive beliefs
- Working with command hallucinations
- Working with schema –bad me, poor me, social rank (e.g. others are more powerful)
- Working with attention
- Working with illness model – Normalisation
- Working in groups – peer support, challenging stigma
- Self-esteem work
- Working with emotion: depression (eg behavioural activation), anxiety (eg stress management, safety behaviours), OCD (eg exposure and response prevention), health anxiety, worry, PTSD
- Social skills/assertiveness training
- Third wave approaches: mindfulness, ACT, compassion
Stages in therapy
- Engagement & assessment
- Promoting self-regulation of psychotic symptoms (coping strategies)
- Formulation/developing shared model
- Delusions & beliefs about voices
- Dysfunctional assumptions about self & others
- Social disability & risk of relapse
Basic structure of CBT for psychosis
- Individual therapy
- Weekly or forthnightly sessions, but vary with need
- Sessions lasting 60 min. but flexible in length
- NICE guidelines suggest at least 16 sessions - but may continue for longer (or end sooner)
- Structured (e.g. having an agenda, setting homework, feedback) but this is very flexibly applied if necessary
- Therapist should have regular supervision
DOs in CBT for psychosis
- Create alliance
- Be curious & collaborative
- Focus on what’s distressing rather than what’s ‘abnormal’ when setting goals
- Focus initially on maintenance cycles & how to change these
- Promote homeworks
- Offer structure
- Understand person’s beliefs and experiences
- Help person discover own best ways of coping
- Protect & enhance self-esteem
DONT's in CBT for psychosis
- Impose your view or push for change
- Try to convince the person to see or try new things
- Try to change symptoms no matter what
- Act as expert
- Say it’s a symptom of mental illness
- Implement CBT techniques at random
- Worry about colluding
CBT for Psychosis – key points
- Tailor CBT to the needs of the individual
- Prioritise engagement
- Always show the person empathy
- Treat as the primary goal the reduction of distress
- Establish a collaborative not a combative approach
- Work on delusions and hallucinations gently, in the context of a formulation.
- Work on activities, depression, and anxiety throughout where appropriate.