PS5306 Lecture 26-11 - Dr Anna Georgiades PDF

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Dr Anna Georgiades...

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26-11-18 CBT for psychosis Learning outcomes - Brief introduction to psychosis - NICE guidelines - CBT for psychosis - Engagement - Formulation - Intervention - Relapse prevention What is psychosis? - Psychosis is an umbrella term to denote a reality distortion experience - Psychosis is a condition in which the functioning of a person’s brain is disrupted, leading the individual to have distorted thoughts, perceptions, emotions, and behaviour - Typically a person with symptoms of psychosis may experience: - Confused thinking and speech - Unusual sensations - Difficulty in distinguishing what is real from what isn’t - Related diagnoses: - Schizophrenia - Schizoaffective disorder - Bipolar disorder Five key features of psychosis - Hallucinations - Hearing voices or seeing things that no one else can hear or see - A hallucination can occur in any sensory modality (eg. sight, sound, smell, taste, and bodily sensations) - Distressing beliefs - An unfounded, preoccupying, firmly held, distressing belief (eg. about being watched, monitored, followed, harmed, or interfered with in some way) - Reduced functioning symptoms - Underfunctioning (eg. lack of motivation, energy, and pleasure; social withdrawal; emotional flat; less than normal levels of speech in terms of amount and content; difficulty paying attention) - Poor insight - Impaired awareness of the illness and of the need for treatment - Thought disorder - Disorganised thoughts and speech

NICE psychosis guidelines (2014) - “CBT should be delivered on a 1-1 basis over at least 16 planned sessions” - Aims to establish links between thoughts, feelings, or behaviours with current or past symptoms, and/or functioning - Promotes alternative ways of coping with symptoms - Reduces distress - Improves functioning - “Family interventions should be carried out for between 3 months and 1 year, and include at least 10 planned sessions” Aims for CBT for psychosis (Fowler et al, 1995) - To reduce the distress and interference that arises from the experience of psychotic symptomatology - To reduce emotional disturbance - To promote the active participation of the individual in the regulation of risk relapse and social disability Overview of main concepts - Engagement, therapeutic relationship, and assessment - Formulation - Then depending on formulation: - Intervening with delusions and hallucinations - Targeting negative self-evaluations, depression, anxiety, and social functioning - Relapse prevention Why do we need CBT for psychosis? - NICE guidelines suggest that CBT and medication prove to be most effective forms of treatment - Antipsychotic medications are only partially effective for people with psychosis (Smith et al, 2010) - 40-50% of cases show a good response - 30-40% of cases show a partial response - 20% of cases are treatment resistant - Adherence to prescribed antipsychotic regimens is typically low, and psychosocial interventions can enhance medication adherence (Smith et al, 2010) - Persisting positive symptoms (40% of cases) - Recurrent acute episodes (80% of cases) - Substantial comorbidity (eg. anxiety and depression) (70% of cases) - Enduring social disability with poverty, unemployment, and restricted life (60-80% of cases) - Suicide (10% of cases) Engagement

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Convey that problems are taken seriously Listen empathically Give ‘pocket summaries’ - Be very human, ask more, be interested, - Always check in by repeating back what they’ve said - Prompt them to reflect Suggest or enhance coping strategies if there is immediate concern Collaborative and flexible Starting point is neutral stance Care not to induce high emotional arousal Sensitive to mental state Explain what is likely to happen in therapy Do not start challenging delusions: listen and understand View client as reasonable and rational - trying to make sense of difficult experiences Always elicit feedback

Potential problems in engagement - Voices - Paranoia - Thought disorder - Concentration - Sessions too stimulation/confusion/aversive - Difference of views - Client thinks therapist believes them to be mad, foolish, or won’t believe them - Worries about being admitted - Not wanting to talk about past experiences Overcoming problems in engagement - Anticipate and accept voices in the session, commenting on the session and on you - Can you hear the voices now? - Anticipate and accept paranoia affecting therapeutic relationship - Is it difficult to talk about this today? - Is it hard to trust me right now? Engagement - Meet the person, not the problem - Acceptance of client and their distress - It can be useful to check out any questions or concerns you had about today’s meeting, me, or the therapy - Commitment to openness and collaboration - ‘Your experience at that time was…’ rather than ‘so you believed that...’

Assessment Psychosis-specific - Cognitive biases (jumping to conclusions, theory of mind deficits, external attribution biases, need for closure, belief inflexibility) - Cognitive deficits (difficulties in concentration, planning, etc.) - Attitude towards medication - Risk (eg. complying with voices, acting on delusions) - Insight (awareness of the illness and of the need for treatment) Delusion-specific - Content - Conviction, preoccupation, distress - Behavioural impact - Initial formation (eg. life events, daily stressors) - Day-to-day examples - Clarify thoughts/beliefs/emotions/behaviours - Maintenance factors (other psychotic symptoms, emotional processes, safety behaviours, etc.) - Change over time - Develop hierarchy of distressing beliefs Voice-specific - Triggers: environmental (when, where, etc.) and internal or emotional (eg. anxiety) - Consequences: behavioural and emotional, as well as impact on general functioning - Frequency, content, number, location, type - Resistance vs. compliance with voices - Coping strategies - Beliefs about voices - Identity (who are they? beneficial/harmful?) - Cause/origin (what causes them? where do they come from?) - Power (how powerful are they?) - Control (how much control do you have over the voices?) Person-specific - Personal beliefs (eg. religion) - Relationship with services - Social support and social relationships - Short and long term goals and plans - Core beliefs, dysfunctional assumptions and schemas (sometimes) - Life history (sometimes)

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Daily activities

Secondary difficulties - Other emotional problems - Low mood - Anxiety - Worry - Low self-esteem - Intrusive thoughts/images - Substance misuse Therapeutic goal setting - Collaboratively decide aims of therapy with client: - Reduce distress caused by your beliefs/voices - Finding out more about what is going on - Examining your experiences in more detail - Trying to reduce the confusion caused by all these events - Helping you to cope with it Formulations - Need to develop a symptom specific personalised, idiosyncratic formulation for clients with psychosis informed by a biopsychosocial approach - They must be personalised and symptom specific - Must understand the person in front of you Beck’s cognitive model Early experiences (trauma-abuse) → core beliefs (I’m worthless/bad) → assumptions/rules for living (if… then) → triggering events (mugging) → thoughts/feelings, behaviours/coping, bodily sensations (psychosis, avoidance, hypervigilance) Psychological formulation Situation: In the supermarket → Thought: Undercover police are monitoring me (bc im bad) → Feeling: Anxiety → Behavior: Wearing sunglasses and hat to avoid detection Go to the supermarket accompanied by husband Avoid going to the supermarket whenever possible - Behaviour does not allow the client to find out that their feared predictions may be unfounded, which therefore perpetuates their

suspicious beliefs - Additionally, acting conspicuously may inadvertently be drawing more attention themselves, further confirming their beliefs about being monitored ABC model (Antecedent, Behaviour/Belief, Consequences) A B Antecedent Images, thoughts, beliefs about Events self and others, beliefs about Situations voices, rules Sensations Triggers ABC model of paranoia A See a man on the bus looking at his mobile phone and then glances at me.

ABC model of voices A Hears and unpleasant male voice and sees shadowy image “You are useless, you should kill yourself…”

C Emotion, behaviour (urge and action) body state

B He’s a spy monitoring and following me. He is working for my employer, as they want to make my life miserable bc I made a mistake at work .

C Anger Urge to run out and shout Action: sit still and get off the bus at the next opportunity Burning physical feeling

B It is an evil spirit punishing me for my actions; it rules my life, I cannot control it, I must be bad. It must be right.

C Fear, despair, helplessness Attempts to struggle and resist Partial compliance (self-harm)

Cognitive approach to psychosis - Central assumption of the cognitive approach to psychosis is that beliefs and experiences of psychosis may derive from cognitive processes, which are on a continuum w normality - Assumption is that people with psychosis, like all of us are attempting to make sense of their world and experiences Delusions - Normalisation and destigmatisation - These experiences are common, occur in nonclinical populations, and under enough stress, anyone can develop these experiences - Normalise these experiences to the client, empathise - Developing and checking out alternative explanations using socratic dialogue - Unravel the flaws of their psychotic web of storytelling

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- Find the chinks, the untruths Trying to reduce the most distressing aspects within the delusion systems Reduce worry and rumination Enhancing coping strategies

Developing and checking out alternative explanations - Summaries belief and elicit alternative explanation(s) - Can you see any other possible ways of making sense of what is happening - If no alternative emerges from exploring doubt, offer one tentatively - Belief and alternative assessed in light of available evidence and usefulness (impact on daily life) Do’s and Don’ts - Do: - Create alliance - Set goals, promote homework, offer structure - Understand client’s appraisals of their experiences in the context of their history and recent events prior to the onset of their psychosis - Create a personalised formulation - Intervene according to your forumulation - Target areas of distress and disability - Enhance coping strategies - Acknowledge your own limitations - Don’t: - Impose your view - Try to convince the person to see or try new things - Try to change symptoms no matter what - Act as expert - Say its a symptom of mental illness - Implement CBT techs at random - Be inconsistent or interpretive...