CBT for psychosis

1. CBT for psychosis PREP Prevention and Recovery of Early Psychosis Kate Hardy, Clin.Psych.D Post Doctoral Fellow Prodromal Assessment, Research and Treatment Team (PART), UCSF Kate.Hardy@ucsf.edu

2. Objectives • Be able to differentiate between the terms ultra high risk and first episode psychosis • Have an understanding of CBT in relation to psychosis and the evidence base behind this • Be able to recognize the key aspects of CBT for psychosis including the reduction of distress rather than the removal of symptoms • Have reviewed any concerns regarding practicing CBT for psychosis

3. What is psychosis? • Positive symptoms • Negative symptoms • Disorganized symptoms • Associated mood symptoms

4. Psychosis: the early course premorbid phase Early Detection & Intervention in the at-risk phase Early Intervention after onset of psychosis (EIS) Psychosis “DUI” very early symptoms psychotic symptoms Treatment & Recovery Relapse? The typical course of psychosis

5. Phase specific psychological treatments • AT RISK PHASE – identify symptoms and prevent transition to psychosis • ACUTE – maintain safety, decrease positive symptoms, decrease associated distress • RECOVERY - promote medication adherence, identify early warning signs and develop relapse signature

6. Ethics of intervening in the at risk period • Use of anti psychotic medication with young people who don’t have a diagnosis of psychosis • Stigma associated with treating individual for something they don’t yet have

7. What is CBT for psychosis? • CBT focuses on reduction of emotional distress (depression, anxiety, trauma etc) through altering cognition and behavior • In psychosis – focus is on a cognitive model of the formulation and maintenance of positive symptoms • Also ‘affective disturbance’ influences and maintains this process

8. What is CBT for psychosis - II • Focus is still on collaborative approach • Client’s perspective is taken seriously • Shared formulation developed to attempt to understanding the meaning of psychosis to the individual • May offer more flexibility in duration of sessions, frequency, goals etc to accommodate difficulties with attention and concentration

9. CBT, psychosis and distress • Birchwood et al. (2004) - not all distress in psychosis arises from positive symptoms • Focusing purely on delusions/hallucinations will not address other sources of distress • Other sources of distress include post psychotic depression, PTSD, childhood trauma • Argue that CT should focus on reducing distress and not on reducing symptoms

10. Deconstructing Schizophrenia • Psychotic symptoms on a continua • Questions validity of term ‘schizophrenia’ and proposes that we focus on individual symptoms • Cognitive processes and biases maintains misperceptions • Processes and biases amenable to CBT intervention

11. Clients’ understandings of psychotic experiences Jim Geekie (2004) • Research conducted with 13 participants in NZ • Came from observation that clients he was working with focused on ‘explanatory models’ • Variety of ways in which people understand their experiences • Welcome opportunity to talk in depth about what experience means to them individually

12. Cautions against telling the client what their experience is or what it means – may lead to further invalidation • Important to recognize that clients want to be active participants in the process of ‘sense making’ • Not undermining the medical profession but encouraging acknowledgement of multiple perspectives