Cognitive Behavioral Therapy for Psychosis: A Research Update

1. Cognitive Behavioral Therapy for Psychosis: A Research Update Kim T. Mueser Center for Psychiatric Rehabilitation Boston University (With contributions by Cori Cather, Jen Gottlieb, Eric Granholm, and Kate Hardy)

2. Disclosure • All my clothes were made by my son, J. Mueser • Bespoke Hand Tailored Suits and Shirts • New York City store location: J. Mueser 19 Christopher St. New York, NY 10014 (347) 982-4382 http://jmueser.com

3. OUTLINE • Ancient and recent history of CBT • Background and basic assumptions of CBT • CBT for psychosis (CBTp): Core ingredients and different models • Research on CBTp • CBTp for clients receiving ACT

4. FOCUS ON COGNITIVE MODELS OF PSYCHOLOGICAL ADJUSTMENT “People are not disturbed by things, but by the view they take of them.” Epictetus (AD 55-135)

5. Human beings can alter their lives by altering their attitudes of mind…. Be not afraid of life. Believe that life is worth living and your belief will help create the fact. William James Pioneering American psychologist and philosopher 1842-1910

6. ALBERT ELLIS – RATIONAL EMOTIVE BEHAVIOR THERAPY • Innovative straight-talk approach to psychotherapy made him one of the most influential and provocative figures in modern psychology and psychiatry • Challenged the deliberate, slow-moving methodology of Freud, the prevailing psychotherapeutic treatment at the time

7. ALBERT ELLIS: VIEW OF HUMAN NATURE • Humans are born with potential for both rational and irrational thinking • Have biological & cultural tendency to think crookedly & to needlessly disturb ourselves • Learn & invent disturbing beliefs & keep ourselves disturbed through our self-talk • Have the capacity to change our cognitive, emotive, and behavioral processes

8. AARON BECK – COGNITIVE THERAPY (CT) • Noted as one of most influential psychotherapists in changing the face of American Psychiatry since Freud, Beck has enjoyed widespread success and professional recognition as a psychiatrist, theorist, and researcher. • Founder of Cognitive Therapy, a form of psychotherapy that incorporates an information-processing model of human psychology rather than one based on instinct, motivation, or biochemistry.

9. AARON (“TIM”) BECK: COGNITIVE MODEL AND PSYCHOPATHOLOGY • Perceptions of situation lead to automatic thoughts which generate emotional, behavioral, and physiologic response: Core beliefs (schemas) underlie automatic thoughts Situation Automatic Thoughts Emotion Behavior Physiologic Response Beliefs • Distorted perceptions and dysfunctional beliefs are major “underlying cause” of emotional and behavioral dysfunction

10. PRIMARY ASSUMPTIONS UNDERLYING CBT • What you think in a situation influences how you feel in that situation • How you feel influences your behavior, or how you act in that situation or related situations in the future • Sometimes how you feel in a situation influences what you think about it • Learning how to evaluate and correct inaccurate thoughts/beliefs related to negative feelings can reduce those feelings and lead to more effective behavior

11. EXAMPLE • You are walking down the street one day and you see a friend on the other side of the street. You call out to say “Hi,” but he doesn’t respond. • How would you feel in this situation? • How might you behave the next time you saw your friend?

12. Thoughts Mood Behavior THE COGNITIVE-BEHAVIORAL MODEL • Nobody likes me • I am a failure • People want to hurt me • Isolation • Avoidance • Procrastination • Depression • Anxiety • Fear

13. Early experiences lead people to develop core beliefs From core beliefs unhelpful assumptions are generated that organize perception and govern behavior Critical incident triggers the assumptions Leading to negative automatic thoughts, which impact mood, behavior and physiology THE NATURE OF COGNITION

14. BASIC TENETS OF CBT • CBT usually focuses on the present • Collaborative, time-limited, structured • Emphasis on goals, problem-solving, and skill acquisition • Focused on decreasing distress in the service of improving functioning • Clients learn specific skills such as identifying and modifying distorted thinking and using approach rather than avoidance behaviors

15. BASIC TENETS OF CBT (Cont’d) • Insight alone does not produce change • Uses ‘guided discovery’ rather than giving advice (“Socratic Questioning”) • Homework is given between sessions – skill generalization is key • Clients are encouraged to “become your own therapist”

16. First described by Beck (1952) However … Largely overlooked as an intervention for psychosis Prominence of biological/medical models Studies in the 1980’s that reported talking therapies as damaging to people with psychosis Long held assumption psychosis lies outside of realm of ‘normal psychological functioning’ HISTORY OF CBTp

17. RATIONALE FOR CBTp • Persistent psychotic symptoms present in 25-40% of persons with schizophrenia • Persistent psychotic symptoms predict relapses and rehospitalizations and longer hospital stays • High distress, depression, demoralization associated with persistent psychotic symptoms • Barrier to community adjustment, especially social relationships

18. FOCUS OF CBTp • CBTp focuses on reducing the distress caused by psychotic symptoms, including hallucinations and unusual thoughts • Also focuses on supporting functioning by addressing negative symptoms • The interpretation of the event causes distress rather than the event itself • CBTp involves checking the accuracy of interpretations of events • CBTp examines how current behaviors are maintaining the problem • Need to check the helpfulness of current behaviors

19. Symptoms of depression and anxiety Past traumatic events Social skills Negative symptoms including lack of motivation Problem solving and decision making Developing coping skills Relapse prevention planning OTHER TARGET AREAS FOR CBTp

20. CBTpPHILOSOPHY • Not so different from CBT for depression and anxiety • Human experience and behavior exists on a continuum • Psychotic symptoms (and other schizophrenia symptoms) are amenable to cognitive and behavioral interventions • Reduction of symptoms/distress tied directly to personal goals

21. Thoughts Emotions Behavior THE COGNITIVE-BEHAVIORAL MODEL OF PARANOIA • I’m in danger • People cannot be trusted • I’m an outsider • People want to hurt me • Social Isolation • Avoidance • Hypervigilence • Safety Behaviors • Paranoia

22. MAIN TENETS OF CBTp • Symptoms are maintained by appraisal and behavior • Distortions are amenable to cognitive and behavioral approaches • Psychotic symptoms (e.g., delusions) represent an attempt to make sense of negative affect

23. CBTpBASIC COMPONENTS • Time-limited nature • Collaboration • Focus on client functional goals (not just subjective states) • “Normalization” of symptoms and psychotic experiences • Shared case formulation/conceptualization • Assessment precedes intervention • Socratic questioning • Routine monitoring of outcomes • Homework • Use of indigenous supports

24. COMMON CBTp TECHNIQUES • Cognitive Restructuring • Coping Strategy Enhancement • Activity Scheduling • Linking Homework Assignments to Session Content

25. RESEARCH ON CBTp • Over 50 randomized controlled trials • Most studies conducted with outpatients • Length of CBTp treatment typically 6-12 months • Most participants had residual distressing psychotic symptoms, despite some treatment with antipsychotic medication • Disorganization was sometimes an exclusion criterion • Active substance use was sometimes an exclusion criterion • Multiple meta-analyses, some debates

26. Jauhar et al. (2014) Applied stringent masking to analysis and exploration of publication bias CBT has an effect on ‘schizophrenic symptoms in the “small” range Note problem of lumping together CBTp studies with different foci on different symptoms or functional areas (e.g., psychotic symptoms vs. social impairment) (Mueser & Glynn, 2014) Turner et al. (2014) Comparison of psychosocial treatments for psychosis CBTpsignificantly more effective (p<0.05) in reducing positive symptoms than other PSI (befriending and supportive counseling) Social skills training more effective in reducing negative symptoms META-ANALYSIS DEBATE

27. Burns et al. (2014) Meta-analysis for medication resistant positive symptoms ES 0.47 (positive symptoms) and 0.52 (general symptoms) at end of treatment Patients with medication resistant positive symptoms may derive more benefit from an adjunctive psychotherapy… than from adjunctive medications META-ANALYSIS DEBATE (Cont’d)

28. META ANALYSIS OF CBTp RCTs WITH PERSISTENT POSITIVE SXS DESPITE ADEQUATE MEDICATION TRIAL (N = 639) Effect size (g) (Burns et al, 2014)

29. SUMMARY OF EFFICACY DATA Specific, superior small to medium effect on positive symptoms Medium effect on all symptoms Improves overall functioning Reduces time in the hospital Effects are durable over follow up

30. CONSENSUS GUIDELINES THAT RECOMMEND CBTp AS A BEST PRACTICE U.S.: Schizophrenia Patient Outcomes Research Sweden: National Board of Health and Welfare U.K.: National Institute for Health & Clinical Excellence Canada: Canadian Psychiatric Association

31. BEST PRACTICE GUIDELINES “Persons with schizophrenia who have residual psychotic symptoms while receiving adequate pharmacotherapy should be offered adjunctive cognitive behaviorally oriented psychotherapy to reduce the severity of symptoms The therapy may be provided in either a group or individual format and should be approximately 4-9 months in duration. The key elements of this intervention include the collaborative identification of target problems or symptoms and the development of specific cognitive and behavioral strategies to cope with these problems or symptoms.”(PORT, 2009)

32. DO YOU HAVE TO BE AN EXPERT TO DELIVER CBTp?

33. THE SHORT ANSWER IS “NO”! • Trained BA level case managers to deliver “high yield CBTpinterventions” in an open trial • 5-day intensive training with weekly supervision • CBTprated as delivered competently • Positive outcomes on negative and general symptoms, hallucinations; no effect on delusions or social functioning • Encouraging preliminary data on dissemination potential (Turkington et al, 2014)

34. CBTp FOR ACT CLIENTS • ACT services reserved for clients with most severe mental illnesses: • Prominent” treatment-refractory” psychotic symptoms common • High utilization of inpatient services • Difficult to engage in traditional mental health services • ACT has the potential to improve functioning in clients receiving ACT, reduce time to transition to less intensive services • Limited efforts to implement CBTp on ACT teams thus far • Recent attempt to evaluate CBSST for clients on ACT teams

35. Implementation of Cognitive-Behavioral Social Skills Training (CBSST) on Assertive Community Treatment (ACT) Teams: Barriers, Facilitators and Outcomes Eric Granholm, Gregory Aarons, Kim Mueser, DimitriPerivoliotis, Jason Holden, David Sommerfeld & Peter Link

36. 3 CBSST MODULES • Cognitive Skills Module • 3C’s; Behavioral experiments • Mistakes in thinking (All-or-None, JTC) • Target defeatist performance attitudes • Social Skills Module • Four basic communication skills • Meet friends, ask for dates, roommate conflict… • Thoughts about skill performance/success • Problem Solving Skills Module • Five-step problem solving training (SCALE) • Social functioning/recovery goal steps • Thoughts about performance/success

37. 5-YEAR HYBRID TYPE 1 EFFECTIVENESS & IMPLEMENTATION TRIAL • Effectiveness: Randomized controlled trial of N=178 clients with schizophrenia or schizoaffective disorder in ACT vs. ACT+CBSST • 85 randomized to ACT+CBSST: • Program 1 = 13, 19, 15 per team (N=47) • Program 2 = 8, 11 per team (N=19) • Program 3 = 9, 10 per team (N=19) • ACT teams delivered adapted CBSST for up to 18 months • Implementation: Structured, mixed qualitative-quantitative methods (i.e., Concept Mapping) • Focus groups characterized implementation experience from multiple stakeholder perspectives (i.e., consumers, providers, supervisors, agency & CMH administrators)

38. ACT-CBSST PROVIDERS • N=97 providers (min 6-mos at agency) • 7 ACT teams, 3 CMH agencies/programs • One-day workshop (max would allow) • Weekly 30-min consultation meetings • Session audio recordings rated for fidelity (CTS-Psy) with provider feedback (N>600) • CBSST resource website with videos of workshop & role plays demonstrating skills, PowerPoint didactics, handouts

39. PROVIDER CHARACTERISTICS (N=97) • 78% Female; 68% White; Age M=32.9 (SD=8.4) • Discipline: Education: Psychology 24% <MA 52% Social Work 17% >MA 48% MFT 13% No Psychologists SUD Counsel 8% Nursing 5% Voc/Train/CM 31% • 6% licensed • Time at agency: M=16.8 mos (SD=26.6)

40. TOTAL CBSST SESSIONS RECEIVED BY CLIENTS (N=85) Mean=14.2 Median=13 SD=10.4 Range =0-52 Q1: 0-5 Q2: 6-13 Q3: 14-21 Q4: 22-52

41. CTS-PSY FIDELITY FOR PROVIDERS WHO DELIVERED SESSIONS * M CTS-Psy fidelity rating = 36.2 (SD=7.1, Range 15-48); 30 is considered adequate (85%>30) Good Fidelity

42. KEY IMPLEMENTATION FACTORS • Ongoing Training Feedback and Support • Regular expert consultation and coaching, timely fidelity feedback, access to training resources, training that bolsters EBP confidence • Organization and Team Supports • Protected time, systems to monitor and prompt delivery, team/agency leadership prioritization and supports, outcome monitoring • Fit between ACT and CBSST models • Adaptations for team and community delivery, flexibility for complex clients and crisis management model

43. PRELIMINARY OUTCOMES

44. SKILL KNOWLEDGE OUTCOME Granholm et al., JCCP, 2014 d = .35 d = .72 Time: p<.001 Group X Time: p=.024

45. Data under analysis FUNCTIONING OUTCOMES d = .15 d = .29

46. TENTATIVE CONCLUSIONS • CBSST could be implemented on ACT teams, with good fidelity • Difficult to get sufficient dosage of CBSST • Was having different practitioners work with the same client a limitation on developing a working alliance in delivery of CBSST? • Clients demonstrated learning of core skills taught • Some evidence of improved psychosocial functioning

47. TARGETING PSYCHOSIS WITH CBTp AND OTHER EBPS ON ACT • CBTp is important tool for working with clients with persistent psychotic symptoms • Other EBPs may also reduce psychotic symptoms and improve functioning among ACT clients • Different interventions may work for different clients • ACT teams need to provide access to multiple EBPs to serve these clients • Example: Supported Employment and Illness Management and Recovery (IMR)

48. ILLNESS MANAGEMENT AND RECOVERY (IMR) • Focuses on helping people set recovery goals and achieve those goals through learning improved illness management information and skills • Extensive, standardized curriculum taught with psychoeducational, motivational, and CBT techniques • Shown to improve course of severe mental illness, including reduction of hospitalizations in clients receiving ACT services (Salyers et al., 2011)

49. SUPPORTED EMPLOYMENT • Practical help for getting and keeping competitive jobs for clients who want to work • Shown to be more effective than other vocational programs, including for ACT recipients (Gold et al., 2004) • Employment associated with modest reductions in psychotic symptoms (Bell, Bond, Mueser studies) • In 5-year RCT, more clients in supported employment worked in competitive jobs, were less likely to be hospitalized, and had better quality of life than those receiving usual vocational services (Hoffman et al., 2015; Jackel et al., 2017) • Higher employment rates mediated reduced risk of relapse and improved quality of life • Work may be good therapy

50. CONCLUSIONS • CBTp targets distress related to psychotic symptoms, and other symptoms and functioning • A strong evidence supports CBTp for persons with SMI, and it is recommended by multiple national guidelines for schizophrenia • CBTp is based on CBT psychotherapy model, which emphasizes the role of thinking and beliefs in influencing how people react to events • Limited efforts have focused on implementing CBTp on ACT teams, but it has great potential to improve functioningin this population