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CBT for psychosis - Coggle Diagram
CBT for psychosis
Goals
Learn to cope with unsual experiences
Improve functioning in line with own goals
Come to understand experiences -> empowerment to manage experiences independently
Address depression, anxiety, trauma, emotion regulation etc, as these -> vulnerability, interfering with recovery
Destigmatize experiences
DOESN'T aim to eradicate unusual experiences
Garety et al. (2001) - positive symptoms
Helps person reappraise experience as self-caused, not external
Change negative self-schemata
Compensate for biased reasoning processes
If can't change externalising attribution, can still help to weaken maintenance from safety behaviours, disrupting vicious cycle
To bear in mind
working with belief systems
aim is to reduce distress - don't challenge beliefs if they can't
they may have had a traumatic journey to therapy
especially if racial minority, esp Black African/Caribbean (MHA Statistics 2020-2021)
the CBP service will be linked with this for them
experiencing psychosis has likely impacted their mental health
FEP/ARMS often -> significant disability
psychosis associated with self-perceived drop in social rank (Allison et al 2012)
Post-psychosis trauma, depression and suicidality are common
1/2 experience PTSD symptoms, 1/3 full PTSD after FEP
Depression early associated with later depression/suicidality (Upthegrove et al. 2009)
ARMS have high prevalence of suicidal ideation (Taylor et al.,2014)
SU may fear relapse or be avoidant about it
Relapse prevention work can make them feel more in control due to understanding why FEP occurred
If they're deep in delusions and at risk, it might not be the right time for psychology
Cognitive models for psychosis
Stress-vulnerability model
interactions between psycho-social vulnerabilities and stress -> psychosis
underpins how we intervene
Cognitive model of positive symptoms of psychosis (Garety et al. (2001, 2007))
Biopsychosocial vulnerability due to socio-cognitive background
Including trauma
High rates in psychosis (Varese et al 2012)
Higher prevalence of PTSD
Associated with worse clinical outcome (Grubaugh et al 2011)
Stressful events
Emotional changes
Can lead directly to +ve symptoms without cognitive changes, but this is rare
Life events disturb affect, directly activating bias appraisal
More likely delusions than hallucinations
Have an anomalous experience & already have cognitive dysfunction
Biased appraisal of experience
+ve symptoms
Maintaining factors
emotional processes
1 more item...
secondary appraisal of psychosis
3 more items...
Those that influence appraisal: cognitive biases, schemas, environment
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Influenced by
cognitive biases
Jumping to conclusions (Bead task, Garety et al 1991)
Confirmation bias
Reasoning and attribution (externalising blame or cause of sensory disturbance)
schemas
"I am vulnerable"
"other people are dangerous"
negative schema s provide content for psychotic attribution as well as increasing vulnerability
environmental factors
Home: feel vulnerable if deprivation, living in high EE or abusive environment
External: danger where live, stigma/discrimination, religious environment
if understand these are affecting your appraisals, can take a step back
social isolation: don't have sources for more normal explanations
Emotional changes (see left)
E.g. hearing scary sound -> demons!
losing job -> colleagues are conspiring against me!
Externalising appraisals are the defining feature - if you can reject externality, you can self-correct
Perceptual, noticing significance, feeling others control self
People really
do
have threat in their lives - we should acknowledge their heightened sense of threat is understandable
More complex - wouldn't give to patient
Doesn't include -ve symptoms, though appraisals may -> them
Extension to a specific symptom - persecutory delusions (Freeman et al. 2002)
Important symptom because
Likely common maintaining factors with anxiety disorders
Common, associated with distress and can lead to actions that -> hospitalisation
differences from Garety et al (2001)
Focus on processes associated with anxiety
Different maintenance factors
Includes aspects of persecutory belief content
differences from Bentall (1994)
Holds that sufferers have an internal negative self-schema but don't want to admit that to themselves, so they blame external things for bad events
but evidence shows this is only true for a minority
better evidence that they have an externalising self-schema
people with these delusions are more likely to put themselves down
Model
Trigger
Anomalous experiences/ambiguous events/arousal
Search for meaning
Influenced by emotion (anxiety, beliefs about the self and others), cognitive biases as well as the experience/event/arousal
Search for an explanation
Persecutory belief
Mediated by beliefs about illness, social factors, belief flexibility
Maintenance
Splits maintaining factors
Reinforce confirmatory evidence
Attentional bias
Behaviours that engender conflict
Discard disconfirmatory evidence (e.g. the worst doesn't happen)
Employ safety behaviours
"It didn't happen because I did x"
Develop further delusions
"They're trying to lull me into a false sense of security"
Encouraged by belief-related anxiety
2 paths to emotional distress
Directly from content - pervasive threat, persecutors are powerful
Further appraisal
I have no control, I'm sad because this is horrible
Which is more important varies between people
Clinical implications
Inform any discussion of how we deliver CBT
Morrison (2001)
Trigger/situation
What happened
How you make sense of it (thoughts
Beliefs about self/others
Influenced by life experiences, thoughts, behaviours and feelings
What you do when it happens (behaviour)
How it makes you feel (feelings)
Basic CBT
Unsual experience/belief
Beliefs/interpretations/appraisals
Thoughts/emotions/behaviour/body 'hot cross bon'
Behaviours can be avoidance or isolation, which reinforce thought that you're not good enough etc.
Identifying vicious cycle isn't a bad thing because can break out of it
Not the event that causes distress, it's the beliefs and thoughts
Work around appraisals, feelings, behaviours
Simplest, most common approach
Delivery
Stages of CBPp
Intervention
Psychoeducation
Introduce stress-vulnerability model
Offer psychological perspective on experiences
Normalise experiences
Clear that you believe they're experiencing what they say they are
Coping strategies
Start here, then they can start to challenge beliefs
Different from classic CBT
E.g. things they can do to make themselves feel safer and leave the house, e.g. wear headphones so doesn't look odd that they're talking to themselves
Behavioural
Behavioural activation
Improves mood
Dropping safety behaviours
Where these are maintaining distress e.g. complying with voices
Reducing engagement with belief systems
Graded exposure
Like in anxiety work
Behavioural experiments
Be attentive, collaborative, "how did you feel?" rather than "I told you so" if did behaviour and no negative outcome
Working with delusions
Aim is to reduce impact and distress
Make sure there's an acceptable alternative in place before challenging delusional belief
Start with less strongly held beliefs
consider available evidence
test beliefs and alternative with behavioural experiments
Metacognitive training to manage reasoning/attributional biases
Create cognitive 'flexibility'
Like in normal CBT, written records
Freeman et al. (2002) recommendations for persecutory delusions
Rapport is key, as there's a high level of threat belief
Sensitive to therapist thinking they're 'mad' - construct non-stigmatising alternative explanation
based on their cognitive model
Use normalisation, talk about cognitive biases
Main goal: change degree of conviction
Discuss the details of the threat, as they may be able to challenge it at certain points
Work in coping strategies that reduce focus on delusions
But reduce safety behaviours to test the threat belief indirectly
Use individualised approach for maintenance factors
Discuss links between delusion content and emotion
Is normalising, brings up beliefs
Model includes importance of their social world for maintenance
discuss relationships and beliefs about others
Working with voices
Like in delusions, but also
Triggers?
Beliefs about level of power/control of voice on them?
Meanings and atributes they give to the voice and how they response to that
Consequences of non-/full compliance?
Possibly reframe as communicating, develop different kind of relationship
Griffiths et al 2012 model shows how experience, power beliefs, behavioural and emotional consequences and background schema interact
CBT work not specific to unusual experiences
Schema/core belief work
e.g. someone may have low confidence/self-esteem, need to bolster to be able to cope
Trauma work
Campodonico et al. (2022) SU perspectives on the effects of not being able to talk about it
Family work
Assessment and goal-setting
Get info on
maintenance - particularly important
triggers
consequences
onset
appraisals of unusual experiences and meaning for self
be curious - don't assume how they respond to experiences
Goals
Collaborative
May take several sessions
Negotiation
Therapy not just to 'offload'
SMART
Manage expectations - you may still hear voices, but feel better about it
Relapse prevention
Identify triggers/stressors
Document early warning signs (T, F, E, B)
Card sort
Less stigmatising, normalising
Create timeline
Identify action plan
Not perfect solution, tool to give them agency
Engagement
Initial
Explore how they felt about coming to the meeting
Normalise any feelings of paranoia, anxiety, voices
Validate success of even turning up
Convey: problems taken seriously
Listen empathically
Give ‘pocket summaries’
Suggest/enhance coping strategies if immediate concern
Collaborative & flexible
Start from neutral stance
Don't induce high emotional arousal
Formulation
Early: share cross-sectional here and now formulation
situation -> thoughts, behaviour, feelings
highlight vicious cycles, potential coping techniques
Later, more longitudinal/complex
Separate from more complex, non-shared formulation
New directions
Target specific processes
Use technology
GAMEChange VR (Freeman et al., 2022)
Virtual reality for anxiety/agoraphobia in psychosis
AVATAR Therapy (Craig et al., 2018; Garety et al., 2021)
Relational approach to distressing voices
Feeling safe programme (Freeman et al 2021)
Address maintenance factors of persecutory delusions
SlowMo Therapy (Garety et al 2021)
Address paranoia
Help specific sub-populations
STAR trial (Peters et al., 2022)
Psychosis + PTSD
NICE guidelines
Preventative/FEP
Full range of interventions to be offered, including psychological
Subsequent episodes/SCZ
Psychological interventions e.g. CBT + meds
CBT details
1:1, 16+ sessions
Manualised
Include thoughts, feelings etc link
re-evaluations of perceptions etc
Plus 1+ of
thought/feeling etc monitoring
alternative ways of coping
reducing distress
improving functioning
Expert opinions on necessary components (Morrison et al. 2010)
High consensus on engagement, structure, principles, formulation, assessment, model, homework, change strategies, therapist assumptions
But it has collaboratively negotiated targets, so all aspects aren't always appropriate
Better to follow a decision tree and remain flexible to that patient
Note: this is just opinion - don't have evidence for which components -> good outcomes
Rationale
Issues with meds only
Medication adherence is poor
56% non-adherence (Semahegn et al. (2020)
Discontinuing medications increase relapse rate x5 (Robinson et al. 1999)
Side effects reduce medication adherence
Persisting positive symptoms (40%)
Recurrent acute episodes (80%)
Depression & anxiety common (70%)
Enduring social disability with poverty, unemployment & restricted life (60-80%)
Suicide (10%)
Meds & community support only partially effective for 40% (Kane, 1996)
Efficacy of CBTp
Small to moderate effect size (0.09-0.49)
Risk of bias?
Jauhar et al. (2014
Non-significant effects in studies at low risk of bias
No evidence of publication bias
Lower effect size when sources of bias controlled for
Blinding moderated effect sizes
Inverse relationship between methodological rigour and effect size (Wykes et al., 2008; Jauhar et al., 2014).
but see Turner et al. (2020) higher effect sizes if low bias and van der Gaag (2014) higher if blinding for hallucinations
Auditory hallucinations, delusions (van der Gaag, 2014)
small to medium effect sizes
pooled 15 studies: 0.44 auditory hallucinations
was better than other active treatments
so more effective for hallucinations than delusions - maybe do targeted CBT e.g. Trower et al. (2004) for command hallucinations
pooled 12 studies: 0.36 delusions
no better than other active treatments
data heterogeneous
unblinding increased effect size
worsening of delusions in 2 trials where patients medication resistant
Overall symptoms in those whose symptoms are persistent (Burns, 2014)
Better than other interventions (Turner, 2014)
May not be effective for relapse in the long run
Bird et al. (2010) review - 4 trials
Reduced mean +ve and -ve symptoms up to 2 years followup
Not significantly better than standard care for relapse by 2-year followup
Limitations: only 4 trials
Strengths: Looked at long-term followup, low heterogeneity
Jauhar et al. (2014) - small effect on symptoms
Turner et al. (2020) m-a - small-medium effect sizes (c. 0.34) for hallucinations/delusions, up to date with lots of studies
Though didn't consider long-term outcomes
even if low bias
But combining heterogeneous trials = reflects clinical complexity of psychosis population (Peters, 2015)
Shouldn't focus on symptom severity to measure CBTp effectiveness? (Birchwood & Trower, 2006)
Trials using psychological outcomes have higher effect sizes
Compliance with command hallucinations (Trower et al., 2004) - though still distress, depression
Global functioning (Grant et al., 2012),
Psychological well-being (Freeman et al., 2014)
Long term effectiveness in routine clinical practice (Peters, 2014)
Psychological issues that need addressing
Often relationship with trauma
Buswell et al. (2021) Prevalence of PTSD
Important to make sense of experiences to move forward and recover
Aim
Doesn't aim to get rid of psychotic experiences
Support client with coping, appraising in less problematic way, understanding, improve functioning, address depression, anxiety, trauma, emotion regulation
What is psychosis?
On a continuum
Sizeable proportions of the non-clinical population have some symptoms present in psychosis
e.g. 25% of people experience hallucinations at lease once (Bentall et al. 1989)
Biosychosocial: Stress-vulnerability model
