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Psychosis: Counseling the Hallucinating or Delusional Patient. Presented by Ron Broughton, M.Ed., L.P.C. Chief Clinical Officer Brookhaven Hospital Tulsa, Oklahoma. Objectives. O verview of medications & efficacy Historical examination of the role of psychotherapy with psychotic patients
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Psychosis:Counseling the Hallucinating orDelusional Patient Presented by Ron Broughton, M.Ed., L.P.C. Chief Clinical Officer Brookhaven Hospital Tulsa, Oklahoma
Objectives • Overview of medications & efficacy • Historical examination of the role of psychotherapy with psychotic patients • Review recent research of CT/CBT • Learn specific therapy strategies for psychosis • Overview the of ABC model
Definitions • Delusion: a false belief based on an incorrect inference about external reality that is firmly sustained despite what almost everyone else believes, and despite what constitutes incontrovertible and obvious proof or evidence to the contrary. • Hallucination: a sensory perception that has the compelling sense of reality of a true perception but that occurs without external stimulation of the relevant sensory organ • Is it inside or outside? Interestingly, the DSM-IV “makes no distinction as to whether the source of the voices is perceived as being inside or outside of the head.”
Medication vs. Therapy Medication Superior Focus On Problem Solving Experienced Therapists Better Outcomes* Psychotherapy 1960-1975
The Early Theme • Psychodynamic approaches not effective • Strong therapeutic rapport • Personal therapy more effective • Experienced clinician + individualized approach = better outcome
An Evolution Begins Creativity is a drug I cannot live without. --Cecil B. De Mille
The Late 90’s Results Compared to supportive & psychoeducational treatment
The New Statistics Don’t Forget Your Favorite College Course
Recent ResearchSivec, H.J. & Montesano, V.L., 2012 • Effect size: .20 small .50 medium .80 large • Meta analyses indicate CBT .35-.40 • Three months follow-up .06-.40 • One year follow-up .32 • Majority of reviews favorable • CBT-P recommended in Europe and U.S.
CBT Research & Hallucinations Reduces & decreases severity
CBT Research & Hallucinations Increases quality of life
CBT Research & Hallucinations CBT Coping Skills Medication Family Therapy Integrative Approach
CBT Research & Hallucinations Overall, CBT IMPACTS Hallucinations
CBT Research & Delusions Studies Have Mixed Results
CBT Research & Delusions • Some no effect until follow-up • Early decrease, not @ follow-up • Others: • 1/3 with decrease in conviction, preoccupation & anxiety • 1/3 No change • 1/3 In between
Client Satisfaction • Was treatment positive/helpful? • CBT = 70% “Yes, definitely” • ST = 37% • TAU = 30% Reason unclear, perhaps the therapeutic relationship?
Strategies Establish a strong therapeutic rapport
Strategies Stress reduction Relaxation techniques to stabilize Systematic desensitization to stabilize 5,4,3,2,1 to stabilize Normalize the experience DoNot use “delusion, hallucination, psychosis” Know the belief well
Strategies Verbal challenge—the evidence Voice logs Client write out delusional content Evidence logs Change topic if client agitated Relapse prevention plan
Therapist Role—Some Tips • Avoid waiting for the “meds to kick in” • Be reliable, predictable & dependable • Simple, honest accurate communication • Have a healthy curiosity—reflection & restatement of content • Walk in the delusion, don’t collude with it • Restrict use of silence, or watch the eyes • If agitated, go to a neutral topic
The ABC Model for PsychosisThe Philosophy Noumenon An object as it is in itself, independent of the mind.
The Philosophy Our reality is interpreted through our senses & beliefs, The “B” of the ABC Model
Delusions on a Continuum Less Normal More All of us fall on the continuum.
5 Principles of the ABC Model • All clinical problems are C’s. • Problems arise from B’s not A’s. • There are predictable connections between B’s and C’s. • Core B’s arise from early experiences. • Weakening beliefs weakens associated distress & disturbance.
Eight Basic Steps • Client defines a problem • Assess A or C • Assess the one that remains • Connect A to C & determine that is the clients primary worry • Assess beliefs, inferences & evaluations
Eight Basic Steps • Formulation: • Show the B-C connection • Offer a developmental formulation • Set client’s goals & consider his options • Avoid or escape • Do nothing • They can change them in some way • Reduce by changing core beliefs
Eight Basic Steps • Challenge beliefs • Disputing and testing inferences • Disputing and testing evaluations Note: this is sequence of conceptual steps, not of technical ones. Lengthy & dynamic process.
Case Study #1 • Delusional set • Excessive religiosity • Minimal ADL’s • Reading the Bible and prayer only • Interventions • Assessed A’s • Assessed C’s • Assessed B’s (inferences, evaluation & interpretation) • Challenged B’s • Family therapy
Case Study #2 • Indeterminate delusional set • Highly intelligent • Mathematics wiz • “Word salad” • Interventions • Assessed A’s • Assessed C’s • Unable to assess B’s • Focused on health & safety
Review • Brief overview of medications & efficacy • Historical examination of the role of psychotherapy with psychotic patients • Review recent research of CT/CBT for psychosis • Learn specific therapy strategies for psychosis • Overview the ABC model
Some Conclusions • Therapeutic work lengthy • Rapport is essential • Requires patience and empathy • DO NOT try to convince client • Use Socratic dialogue—client draws on his own experience & doubt • ABC model and schema therapy
Questions? Thank You!