Psychosis: Counseling the Hallucinating or Delusional Patient

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PsychosisCounseling the Hallucinating
orDelusional Patient

• Presented by Ron Broughton, M.Ed., L.P.C.
• Chief Clinical Officer
• Brookhaven Hospital
• Tulsa, Oklahoma

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Objectives

1. Overview of medications efficacy
2. Historical examination of the role of
   psychotherapy with psychotic patients
3. Review recent research of CT/CBT
4. Learn specific therapy strategies for psychosis
5. Overview the of ABC model

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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.

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Charlie Browns View
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Atypical Medications
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Medication Efficacy
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Research on Psychotherapy and PsychosisThree
Recent Eras
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Psychotherapy 1960-1975
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Psychotherapy 1980-1995
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The Early Theme

1. Psychodynamic approaches not effective
2. Strong therapeutic rapport
3. Personal therapy more effective
4. Experienced clinician individualized approach
   better outcome

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An Evolution Begins
Creativity is a drug I cannot live
without. --Cecil B. De Mille
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Evolvement in the Late 90s
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The Late 90s Results
Compared to supportive psychoeducational
treatment
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The New Statistics
Dont Forget Your Favorite College Course
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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.

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CBT Research Hallucinations
Reduces decreases severity
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CBT Research Hallucinations
Increases quality of life
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CBT Research Hallucinations
CBT
Coping Skills
Medication
Family Therapy
Integrative Approach
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CBT Research Hallucinations
Overall, CBT
IMPACTS
Hallucinations
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CBT Research Delusions
Studies Have Mixed Results
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CBT Research Delusions

• Some no effect until follow-up
• Early decrease, not _at_ follow-up
• Others
• 1/3 with decrease in conviction, preoccupation
  anxiety
• 1/3 No change
• 1/3 In between

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Client Satisfaction

• Was treatment positive/helpful?
• CBT 70 Yes, definitely
• ST 37
• TAU 30

Reason unclear, perhaps the therapeutic
relationship?
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Strategies
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Strategies
Establish a strong therapeutic rapport
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Strategies

1. Stress reduction
2. Relaxation techniques to stabilize
3. Systematic desensitization to stabilize
4. 5,4,3,2,1 to stabilize
5. Normalize the experience
6. Do Not use delusion, hallucination, psychosis
7. Know the belief well

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Strategies

• Verbal challengethe evidence
• Voice logs
• Client write out delusional content
• Evidence logs
• Change topic if client agitated
• Relapse prevention plan

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Therapist RoleSome Tips

1. Avoid waiting for the meds to kick in
2. Be reliable, predictable dependable
3. Simple, honest accurate communication
4. Have a healthy curiosityreflection restatement
   of content
5. Walk in the delusion, dont collude with it
6. Restrict use of silence, or watch the eyes
7. If agitated, go to a neutral topic

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The ABC Model for PsychosisThe Philosophy
Noumenon An object as it is in itself,
independent of the mind.
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The Philosophy
Our reality is interpreted through our senses
beliefs, The B of the ABC Model
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Delusions on a Continuum

• Less Normal More
• All of us fall on the continuum.

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5 Principles of the ABC Model

1. All clinical problems are Cs.
2. Problems arise from Bs not As.
3. There are predictable connections between Bs and
   Cs.
4. Core Bs arise from early experiences.
5. Weakening beliefs weakens associated distress
   disturbance.

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Eight Basic Steps

1. Client defines a problem
2. Assess A or C
3. Assess the one that remains
4. Connect A to C determine that is the clients
   primary worry
5. Assess beliefs, inferences evaluations

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Eight Basic Steps

• Formulation
• Show the B-C connection
• Offer a developmental formulation
• Set clients goals consider his options
• Avoid or escape
• Do nothing
• They can change them in some way
• Reduce by changing core beliefs

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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.

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Case Study 1

• Delusional set
• Excessive religiosity
• Minimal ADLs
• Reading the Bible and prayer only
• Interventions
• Assessed As
• Assessed Cs
• Assessed Bs (inferences, evaluation
  interpretation)
• Challenged Bs
• Family therapy

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Case Study 2

• Indeterminate delusional set
• Highly intelligent
• Mathematics wiz
• Word salad
• Interventions
• Assessed As
• Assessed Cs
• Unable to assess Bs
• Focused on health safety

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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

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Some Conclusions

1. Therapeutic work lengthy
2. Rapport is essential
3. Requires patience and empathy
4. DO NOT try to convince client
5. Use Socratic dialogueclient draws on his own
   experience doubt
6. ABC model and schema therapy

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Questions?
Thank You!