Assessment

1. Assessment Life history, critical incidents, current environment, congruence with symptoms Standardised measures PSYRATS BAVQ, IVI, BAPQ Mood, Safety behaviour interview, TCQ etc. PTCI, DES, CTQ, THQ SMART goals, belief ratings etc.

2. Formulation 4 levels: basic / horizontal maintenance internal generation historical / developmental / vertical

3. Basic Formulation EVENT THOUGHT FEELING BEHAVIOUR hear voice it’s the devil scared pray & visit church see ceefax I’m the devil scared burn self p666

4. Maintenance Formulation Triggers (cannabis, paranoid thoughts, arousal, religious ) Hear Voices scared, increased arousal pray, hide in church, no sleep attend to relevant stimuli It is the devil trying to possess make me harm people

5. Historical Formulation Early Experiences mental and sexual abuse from religious mother physical abuse from father to both told to harm father; told she was evil catholicism Beliefs Formed I am evil and the devil is in me I might harm other people Must think good thoughts Thinking something evil is as bad as doing it Critical Incident Raped Hear voices saying bad things

6. Intrusions / event • Social situations / reminders • Flashbacks / dissociation Critical voices • Making sense of things They are talking about me / want to hurt me I’m mad / not normal It’s a Bully from beyond the grave Beliefs / strategies / rules I am vulnerable / useless I am mad / not normal People will hurt you & can’t be trusted ‘Paranoia’ keeps me safe Bullying was my fault If I keep busy or spaced out then I won’t have time to think / feel bad Cog. & Beh. responses Safety behaviours Dissociation Thought supression Avoid situations Run away Look out for danger Don’t express self Mood & physiology Anxious Hyperarousal Paranoid Depressed Sleep problems Experience Bullying Physical Abuse Emotional abuse

8. Experiences that worry me Hear whispering and laughing See bodies See people staring What I make of it They might be ghosts I must be going mad They might harm me What I make of the self / world I should be in total control I am bad Need to be alert for danger Other people cannot be trusted How I feel scared agitated angry sad What I do Try to stay in control of thoughts Hide from ghosts Look out for things happening to me Early experiences Baby brother died, mum blamed me Sexually abused aged 14 Dad horrible to me

9. Formulation Exercise Role play assessment of patient and formulation

10. Video Developing case formulation

11. Exercise Suggest intervention strategies based on formulation

12. Normalising psychotic experiences Trauma (assault, bullying, kidnap, combat) Drug abuse Isolation / Sensory deprivation Bereavement Sleep deprivation

13. Some well known voice hearers: Philosophers and thinkers: Socrates Plato Aristotle Descartes Mahatma Gandhi  Authors, musicians and creativeartists:Jonathan Swift Beethoven Mozart Byron Edgar Allen Poe Charles Dickens Philip K Dick Anthony Hopkins Zoe Wanamaker Paul McCartney Brian Wilson Spiritual and religious figures: Moses Jesus Mohammed Joan d'Arc George Fox (Founder of the Quakers)  Leaders and rulers Alexander the Great Caesar Oliver Cromwell Napoleon Churchill Scientists,Discoverers & Explorers Christopher Columbus Galileo Isaac Newton John Nash Footballers Tony Cascarino Paul Gascoigne

14. “I’ve learnt a lot...erm I guess about mental health it happens to a lot of people and things like... I thought I was abnormal, especially when I was down I thought what is wrong with me erm and [therapist] would always say well would you think somebody was normal if they had green eyes, and you’d be like yeah, and she’d say like... well more people have mental health problems than have green eyes” (8) “…all these thoughts, I was thinking when I felt fine, oh my god they’re crazy but [therapist] helped me to see that the thoughts weren’t crazy, after looking at what happened” (1)

15. Common Treatment Strategies Advantages and disadvantages Normalisation and formulation Evidence for and against Explore meaning / downward arrows Modify environment Belief restructuring: Historical review Meaning of event Continuum Evidence, data log List alternative explanations Conviction ratings Pie chart Refer to feelings and behaviour

16. Common Treatment Strategies Behavioural experiments: Drop safety behaviours Exaggerate and drop Attentional focus Test reality Practical stuff Test alternatives Monitoring Symptom induction Surveys Metacognitive beliefs (e.g. positive/negative beliefs about paranoia/rumination/worry) strategies (e.g. postponing perseverative processing) attentional strategies (e.g. external focus)

17. “We could test out our predictions, and like look for other explanations like, there was some exercises in the CBT that I could do...so eventually I’d feel, like I’d get a de-escalating feeling of anxiety” (1) “I think the evidence thing’s kind of good, sort of it is real and you have to sort of work out well, is it likely to be real. Like if you think, say, people taking thoughts out of my head, and erm, it’s sort of well what’s the proof that they are” (2)

18. Intervention: Delusions Identify thoughts, feelings & behaviour Evaluate advantages and disadvantages Evaluate thoughts: evidence for and against generate alternative explanations advantages & disadvantages Education anxiety, intrusions, metacognition, reasoning biases, thinking errors, selective attention Behavioural experiments

19. Advantages Disadvantages Makes me feel special Keeps my belief in a soulmate Makes life feel special Frustration when Richard and I do not meet. Causes difficulties with present partner Has got me into trouble with the police in the past My psychiatrist thinks this is a problem It upsets my daughter a lot I’m distraught when Richard tells me he is not in love with me Anger towards Richards wife Unable to go away for the weekend as need to stay near house in case Richard decides to come and see me

20. Evidence for “The neighbours are going to attack me” Evidence against “The neighbours are going to attack me” There are rowdy noises from next door I have been assaulted by other people in the past They can read my mind I have seen them 3 times this week and they haven’t attacked me I have never been assaulted by anyone from my street I have never seen the neighbours be violent to anyone I don’t think they are going to attack me when I am drunk or when I am with other people

21. Evaluating interpretations The rowdy noises from next door are due to: Initial belief: The neighbours want to attack me 80% The neighbours are having a party 25% The neighbours are having an argument 50% The neighbours are making noises to wind me up 50% I am imagining the noises 10% The noises are being beamed into the house from outer space 0% Stress, lack of sleep & beliefs are making me misinterpret noises 25%

22. Interpretations of Voices mediate distress identify use modified DTR use questionnaires use interviewing use downward arrows to access personal meaning use content use qualities of voice

23. Interpretations of Voices evaluate by use of list of interpretations generate alternative interpretations relate to normalising information rate & rerate belief each session use diaries / monitoring include how related were the voices to your thoughts or worries or yourself

24. Interpretations of Voices Evaluating... examine evidence for and against including content use shadowing compatibility of modulators behavioural experiments drop/modify safety behaviours manipulate attentional biases control

25. Interpretations of Voices encourage one to be internally generated provide information re: research behavioural experiments using subvocalisation analysis of voice content in relation to thoughts education re: intrusive thoughts identify metacognitive beliefs challenge metacognitive beliefs

26. Video

27. Content of Voices Can mediate distress Identify using: modified DTR shadowing role play diaries

28. Content of Voices Challenge using: link between thoughts and voices evidence for and against alternative explanations role play flashcards

29. Content of Voices & Schema Content of voices often related to experience bullying sexual abuse / rape worthlessness evil guilty threat

30. Content of Voices & Schema Challenge using Padesky’s (1994) techniques: continuum methods surveys historical test positive data logs

31. Why homework? The rationale for homework The idea that homework enhances therapy should be replaced by the idea that therapy enhances homework. Secondarygains of homework active achievement collaborative nature of the therapeutic relationship empowerment

32. 6 golden rules for maximising homework compliance Decide work to be done jointly. Clearly identify the rationale for doing the homework. Check out obstacles. Make the homework meaningful but achievable. Establish prompts. Begin the use of homework from the first session.

33. “I feel if I hadn’t done the homework that I had, then, and showed up to the sessions as well, I think it would have taken me a lot longer” (1) “…when I first like you know got told I was gonna have CBT you just expect you get better but it doesn’t, there’s a lot of like, you got a put a lot in yourself to get a lot out really” (7) “So once we had worked out that I was actually doing it right I could do it by myself” (1)

34. Behavioural experiments A powerful way to test alternative belief derived from verbal testing Facilitates ‘gut’ level change Links behaviour with personal meaning Specifically targeted - increases efficiency and effect Wider range of uses

35. Behavioural experiments Can include: Observations Surveys Acting ‘as if’ Hypothesis testing (A/B) Increasing / Decreasing responses Symptom induction Role plays

36. Issues of design Be collaborative Motivation to complete them Practical implementation

37. ‘People can hear my thoughts’ Behavioural experiments Drop safety behaviours Suppression vs. counter-suppression Recording Deliberate broadcasting to provoke responses Surveys

38. Principles of Cognitive Therapy A cognitive model is required from which to empirically derive effective treatments: FORMULATE USING MODEL What are you concerned about? SHARE A GOAL You are not mad, you are normal: NORMALISE Either it is real or you believe it to be real: SIT ON A COLLABORATIVE FENCE How you appraise events contributes to distress: EVALUATE USING E-T-F-B It’s not always what you think, sometimes it’s how you think MODIFY CONTROL STRATEGIES Test it out – drop your safety behaviours: EXPERIMENT IN & OUT OF SESSION

39. Tips Important to relate to goals (usually emotional change or changing ‘what I do’ to improve QoL) Use match between appraisal and emotion, and emotion and behaviour Only draw in arrows with agreement – otherwise investigate relationships Normalise the ‘story’ Use arrows to plan treatment

40. Tips • Agree a shared goal first and foremost • Explicit structure and labels • Focus on specifics, not general • Leave plenty of time for ‘between session tasks’

41. CBT for psychosis NICE guidelines say at least 16 sessions over at least 9 months Numerous meta-analyses in support (BUT as adjunct to antipsychotics in most participants) Aims to reduce distress and improve quality of life

44. Inclusion criteria 1) either meet ICD-10 criteria for schizophrenia, schizoaffective disorder or delusional disorder or meet entry criteria for an Early Intervention for Psychosis service (operationally defined using PANSS) in order to allow for diagnostic uncertainty in early phases of psychosis 2) either have at least 6 months without antipsychotic medication and experiencing continuing symptoms OR never have received antipsychotics and be currently refusing 3) score at least 4 on PANSS delusions or hallucinations or at least 5 on suspiciousness/persecution, conceptual disorganisation or grandiosity

45. Measures Symptoms: PANSS Psychotic Symptom Rating Scales (PSYRATS; Haddock, McCarron, Tarrier and Faragher, 1999). Recovery A user-defined measure of recovery (QPR; Neil et al., 2009) Functioning PSP

46. CONSORT diagram Referred (n = 43) Assessed for eligibility (n= 26) • Excluded (n= 6) • Not meeting inclusion criteria • (n= 5) • Refused to participate • (n= 1) Enrollment • Allocated to intervention • (n= 20) • Received allocated intervention • (n= 19, 1 withdrew after 1 session) Allocation Assessed n =17 declined n = 1 withdrew n = 2 Follow-Up Analysed (n= 20) Excluded from analysis (n=0) Last observation carried forward (LOCF) at end of treatment analysis (n = 3) LOCF at follow up analysis (n = 5) Analysis

47. Patient characteristics Gender Male N = 10 Female N = 10 Age Mean = 26 Range 16 - 56 Ethnicity White British N = 16 Black African N = 1 Black Caribbean N = 1 Other N = 2

48. Diagnosis Schizophrenia N = 15 Schizoaffective Disorder N = 4 Delusional Disorder N = 1 Disabling hallucinations N = 13 Disabling delusions N = 17 Both delusions and hallucinations N = 10

49. CT 8 therapists contributed to the delivery of CT within the trial. The number of participants treated by each ranged between 1 and 10. participants received a mean of 16.7 sessions (S.D. = 7.26; range 1 to 26) Acceptability: no participant not attending any sessions, and 19/20 receiving 6 or more sessions

50. Effect size analyses (Cohen’s d)