Cognitive Therapy for Psychosis

1. Cognitive Therapy for Psychosis also referred to as, Cognitive Therapy for Schizophrenia Presenter: Ron Unger LCSW 541-513-1811 4ronunger@gmail.com

2. The Essential idea of Cognitive-Behavioral Therapy: • If you learn to think and act differently, then your mental and emotional problems may disappear • You can learn to take responsibility for changing your thoughts and behaviors • though you may need others to help you figure out how to do it

3. From an “Illness Management & Recovery” workbook • “What causes schizophrenia? • “Schizophrenia is nobody’s fault. This means that you did not cause the disorder, and neither did your family members or anyone else. Scientists believe that the symptoms of schizophrenia are caused by a chemical imbalance in the brain.” P. 177 of workbook at http://www.ncebpcenter.org/pdfs/wmrdox/wmr.handouts.pdf

4. The extreme version of the “Medical Model” tries to relieve shame & blame, but it goes too far: Cognitive model: “You aren’t to blame for falling into this problematic pattern, you didn’t know how to anticipate it, but with effort and with help you may learn to get out of it” Shame and Blame model: “you must have chosen to become like this and you could chose to get over it if you want to – pull yourself up by your bootstraps” Medical model: “You have a brain disease and/or a biochemical imbalance: you aren’t responsible, your thoughts & decisions played no role in this”

5. Cognitive therapy for psychosis • Is a systematic approach • With published therapy manuals • Though treatment requires an individualized approach, probably more so than in other varieties of cognitive therapy • Is well researched • At least 36 randomized studies • Showing significant effects on average • (Beck, 2009) • Is on Oregon’s list of “evidence based practices”

6. Cognitive Therapy and Medications • The evidence base is mostly with clients who also took medications • Cognitive therapy worked to reduce the symptoms the medication did not control • As a result of cognitive therapy, clients are often able to use less medication • Case study reports show cognitive therapy is often helpful with clients who refuse medications. • One research study showed cognitive therapy alone was effective in reducing risk for people just starting to experience psychotic symptoms • Morrison, et al., 2004

7. Graph as printed in “Anatomy of an Epidemic” by Robert Whitaker

8. Definition of “psychosis” • "A severe mental disorder, with or without organic damage, characterized by derangement of personality and loss of contact with reality and causing deterioration of normal social functioning.“ • From the American Heritage Stedman Medical Dictionary

9. Social Support and Dialogue • Easily available to those who are “normal” • More difficult to find for those who are “neurotic” • Very difficult or impossible to find for those who are “psychotic” • The more you need it, the less available it is

10. Psychosis contributes to often extreme social isolation Isolation increases likelihood of psychotic symptoms Isolation as contributing cause to psychosis: see http://isps-us.org/koehler/sociocultural.htm

11. Dialogue and the Edge between Balance and Imbalance • Rationality emerges out of dialogue • Not by suppressing "irrational" views • Health is not the absence of disruptive emotions and thoughts • But rather a meta-balance between what is disruptive and what is stabilizing

12. Two extremes, when rational internal dialog is missing: My feelings and emotions give me suggestions about what may be real.  I decide whether they are accurate or not. If they are accurate, I act on them, if not, I just accept them and let them go. My feelings and emotions take over, or tell me what is real: If I'm feeling down then I'm doing terrible, if I feel scared, then I’m in danger, etc. I reject my feelings and emotions, or see them as my enemy: I need to block them out (or drugthem away) Emotional Reasoning, Excess Association Avoiding Emotions, Dissociation

13. One thing that can disrupt internal dialog: Trauma • When arousal is too great, parts of the mind that generate internal dialog evaluating danger can shut down (van derKolk, 2006) • Which can be good in extreme situation • Problem is when it doesn’t start up again afterward • When experience seems too much to face, long term problems can result • Not just PTSD • A host of other problems, including “psychotic symptoms” – (John Read, 2008)

14. What is most essential to CBT for Psychosis: • Establishing and maintaining a good relationship is more important than any other therapeutic activity • So if anything you are doing interferes with the relationship, stop it! • at least until you find a way to do it that does not interfere with the relationship From the book “Cognitive Therapy of Schizophrenia” by Kingdon & Turkington, p 43

15. Another fundamental ingredient: Hope • Modern finding: that mental activity can change biochemistry and eventually brain structure • This finding is known as “neuroplasticity” • A reason for hope • Not really more mystical than the notion that bodily activity can change the body, i.e., exercise changes muscles, etc.

16. Elements of the Cognitive Approach • Goals structured around what client wants • Collaborative Empiricism • Middle ground between confrontation and collusion • Socratic Dialogue • Avoiding the role of “expert” • Curiosity about client’s efforts to make sense • Empathy • Self disclosure

17. CBT for psychosis includes “off the map” exploration: Follows charted routes when that makes sense, but also willing to explore uncharted territory: When I explore uncharted territory, I tend to make charts as I go as much as I can. Therapy by formula: I just do what is in the therapy manual, whether it works or makes sense to the individual client or not. I always know exactly what I am doing though. Columbus therapy: I set off not knowing where I am going, get there & don’t know where I am, then get back and don’t know where I’ve been.

18. Exercise, Phase I: • “Client” identifies a potentially controversial view he or she actually holds • “Therapist” attempts to passionately persuade “client” that the “client” is wrong • This is “brief therapy” so confront the “client” in as strong of terms as possible, showing them how ridiculous their belief is, so they change as quickly as possible!

19. Exercise, Phase II • Engage in discussion about the same belief • Use “collaborative empiricism” • Avoid confrontation or collusion • First, briefly explore why “client” believes it • Then, gently draw out from the “client” any possible reasons to doubt that the belief is completely true • Remember, Relationship First!

20. Normalizing: • Interpreting psychotic experiences as an understandable reaction to events or combinations of events • Reduces the panic and emotional arousal that often leads to more symptoms • Normalizing means looking at psychotic experiences as existing on a continuum with everyday sorts of troublesome experiences and confusion • not categorically different, not “insane” as opposed to “sane” From the book “Cognitive Therapy of Schizophrenia” by Kingdon & Turkington, p 83-05

21. Stress Sense of threat and negative mood leads to hypervigilance for more input from voices (listening harder for them) Hearing a voice Interpret voice as a threat Perception of threat increases negative mood

22. Stress Accepting the voices and taking action to reduce stress results in less stress over time, & less preoccupation with voices Hearing a voice Interpret voice as an effect of stress Accept the voice as a signal of stress, take action to reduce the stress

23. Developing a formulation • A formulation is a hypothesis or story about • what caused problems to develop, and • what maintains the problems • The formulation provides • hope that the problem can be overcome, • as well as suggestions about how to do that

24. What’s causing these weird experiences? Therapist: We can diagnose you with the illness called schizophrenia because you have these weird experiences. Therapist: These weird experiences are being caused by your illness, which is schizophrenia Client: How do you know that I have an illness called schizophrenia? Problems occur when a “diagnosis” is used as an explanation for the problem

25. The traditional explanation is linear and offers little hope for recovery From “Madness Explained” by Richard Bentall

26. From: A Casebook of Cognitive Therapy for Psychosis, Edited by Anthony P. Morrison

27. From: The Case Study Guide to Cognitive Behavior Therapy of Psychosis, Edited by David Kingdon & Douglas Turkington

28. From “Early detection and cognitive therapy for people at high risk of developing psychosis” by French & Morrison

29. From the book “Working with People at High Risk of Psychosis, Page 119

30. A key thing to look for in a formulation: • When efforts to make things better are inadvertently making it worse • As things get worse, misguided efforts to make them better often intensify • Leading to things getting even worse • Without insight into the vicious circle, it just accelerates • Or is perceived to be a result of a “biologically based mental illness”

32. From the book “Working with People at High Risk of Psychosis, Page 119

33. From: Cognitive Therapy of Schizophrenia, by David G. Kingdon & Douglas Turkington

34. A Developmental Formulation Negative identity defined by others, felt crushed Learned how to make up own identity, own world view (drugs amplified this) Often overdid it, getting grandiose or nonsensical, rejecting reason entirely Others couldn’t understand, often had poor relationships But Found some others who could understand & appreciate self, Felt inspired to make more sense to others, resulting in more coherent identity

35. A less extreme story leaves more room for growth & development Evolving Human Story:As I reflect on things, I can develop stories that meet my emotional needs while also allowing me to relate well to others “Psychotic” story: I have to believe this story for important emotional reasons, even if it gets me into serious trouble Psychiatric story:my beliefs and experiences are caused by my disease, for example, schizophrenia

36. Definition of “Paranoia” • A psychotic disorder characterized by systematized delusions, especially of persecution or grandeur, in the absence of other personality disorders. • Extreme, irrational distrust of others. • From The American Heritage® Stedman's Medical Dictionary • (Note that any kind of interpersonal anxiety is on a continuum with “paranoia”)

37. Normalizing: Understanding the Possible Roles of Paranoia • Helps us detect threats • Can make us feel safer • “they won’t slip anything past me” • Gives us someone else to blame • “I’m very competent, but there’s trouble because all these people are against me”

38. When paranoia is protecting self esteem: • Then directly challenging paranoid beliefs may threaten self esteem • So first develop alternative ways to protect a sense of self worth • then can realistically look at evidence for and against paranoid views

40. Vigilance-Avoidance: A source of paranoia • People prone to paranoia tended to look away from threatening stimuli sooner than did non-paranoid people • But then they tended to perceive more threat coming from stimuli others saw as neutral • The “looking away” can be seen as a form of avoidance, meant to lower emotional arousal • But it causes new problems when neutral stimuli then appear threatening & triggers more arousal Green & Phillips, 2004 Social Threat Perception and the Evolution of Paranoia

41. Delusions

43. Traditional Definition of a “Delusion” "A delusion is a false belief held with absolute certainty despite evidence to the contrary and out of keeping with the person's social, educational, cultural and religious background” Hamilton, 1984, as quoted in “Cognitive Therapy of Schizophrenia” by Kingdon & Turkington

44. A couple ways CBT looks at “delusions” differently • People may claim 100% certainty, and seem to ignore evidence, • but when encouraged to be thoughtful, they often change beliefs at least somewhat • There may be a grain of truth (or sometimes much more) in apparently delusional beliefs

45. Four ways of working with probable delusions: • 1. Explore life events preceding development of the belief • 2. Explore & help person learn to relate differently to underlying issues & vulnerabilities • 3. Evaluate the belief by • exploring evidence for and against • developing self-esteem preserving alternatives • testing beliefs • 4. Help the person expand engagement with the world and with other people • which reduces preoccupation with the belief

46. Getting started: Exploring what’s positive about the belief • It may explain certain evidence that otherwise lacks explanation • The person may gain certain advantages by believing it • The belief may be a metaphor for something the person is not able to describe or relate to more directly • Literally untrue, but true in some sense

47. Helping people handle fears about changing beliefs • List advantages & disadvantages of changing • Find alternative ways of accomplishing the purpose of the belief • Help person anticipate how to forgive self if it turns out a view was mistaken • Look carefully at evidence for both sides • this reduces the chance of changing to a new belief that is untrue

48. How to explore a belief that seems delusional: • Suspend your disbelief: stay in “maybe” • Go slow, be diplomatic • Frame the belief as a way the person made sense of specific experiences • Acknowledge and honor evidence that supports the belief • And advantages of having the belief • Be curious about how other possibilities were ruled out

49. When you are ready to weigh the evidence: • Be curious about details and inconsistencies • Ask what was most puzzling about experiences that led to the belief • Notice “safety behaviors” that may be impeding collection of disconfirming evidence • Find ways to gather more data

50. From: Models of Madness: Psychological, Social and Biological Approaches to Schizophrenia, Edited by Read, Mosher & Bentall