Cognitive Therapy for Psychosis

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Cognitive Therapy for Psychosis

• Presenter Ron Unger LCSW
• 4ronunger_at_gmail.com

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The Essential idea of Cognitive-Behavioral
Therapy

• If you learn to think and act differently, then
  your mental/emotional problems can disappear
• You are the one who is responsible for changing
  thoughts and behaviors, though others may help
  you figure out how to do it

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From an Illness Management Recovery workbook

• What causes schizophrenia?
• Schizophrenia is nobodys fault. This means that
  you did not cause the disorder, and neither did
  your family members or anyone else. Scientists
  believe that the symptoms of schizophrenia are
  caused by a chemical imbalance in the brain.

P. 177 of workbook at http//www.ncebpcenter.org/p
dfs/wmrdox/wmr.handouts.pdf
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The extreme version of the Medical Model tries
to relieve shame blame, but it goes too far
Cognitive model You arent to blame for
falling into this problematic pattern, you didnt
know how to anticipate it, but with effort and
with help you may learn to get out of it
Shame and Blame model you must have chosen to
become like this and you could chose to get over
it if you want to pull yourself up by your
bootstraps
Medical model You have a brain disease and/or
a biochemical imbalance you arent responsible,
your thoughts decisions played no role in this
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Cognitive therapy for psychosis

• Is a systematic approach
• Is well researched
• At least 36 randomized studies (Beck, 2009)
• Is considered an evidence based practice
• Being systematic and evidence based provides
  some weight when attempting to push back against
  the medical model

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Cognitive Therapy and Medications

• The evidence base is mostly with clients who also
  took medications
• Cognitive therapy worked to reduce the symptoms
  the medication did not control
• As a result of cognitive therapy, clients are
  often able to use less medication
• One pilot study, and case study reports, show
  cognitive therapy is often helpful with clients
  who refuse medications.
• Morrison, et al., 2011
• One study showed cognitive therapy alone was
  effective in reducing risk for people just
  starting to experience psychotic symptoms
• Morrison, et al., 2004

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How does it work?

• A collaborative, respectful relationship is key
• Therapist does not act like a know it all
• Normalizing seeing psychotic problems as just
  more extreme versions of everyday ones
• Focusing on the individual story of how the
  current problem came about and was perpetuated

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State of High Stress or Trauma
High emotional arousal, fight or flight
response to the voice
Hearing a voice
Interpret voice as a threat
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Hallucinations

• Cognitive therapists see these as just our own
  thoughts or representations of something in the
  world,
• temporarily mistaken for something coming in
  directly from the external world
• Cognitive therapists dont try to get rid of
  these, just change the way we understand and
  relate to them

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Various ways of working with an apparently
delusional belief

• 1. Explore history
• 2. Is it metaphorical?
• 3. Learn to cope better with underlying
  difficulty
• 4. Increase awareness of evidence pro con,
  alternate possible interpretations
• 5. Find ways to live well despite having the
  belief

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Cognitive Therapy for Psychosis

• Presenter Ron Unger LCSW

4ronunger_at_gmail.com
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Advantages of cognitive therapy for psychosis

• It focuses on simple patterns which, if not
  interrupted, can generate complex problems
• It is respectful and collaborative
• At least when done well
• It has very specific ideas about what people can
  do to resolve problems with psychotic experiences

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Definition of Psychosis

• A severe mental disorder, with or without
  organic damage, characterized by derangement of
  personality and loss of contact with reality and
  causing deterioration of normal social
  functioning.
• Definition found in American Heritage Stedmans
  Medical Dictionary

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Social Support and Dialog

• Easily available to those who are normal
• More difficult to find for those who are
  neurotic
• Very difficult or impossible to find for those
  who are psychotic
• The more a person needs it, the less available it
  is
• Especially when mental health workers refuse to
  discuss psychotic experiences or beliefs

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Psychosis contributes to often extreme social
isolation
Isolation increases likelihood of psychotic
symptoms
Isolation as contributing cause to psychosis
see http//isps-us.org/koehler/sociocultural.htm
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Dialogue and Rationality

• Rationality emerges out of dialogue
• Not by suppressing "irrational" views
• Instead, it is engaging one view in dialogue with
  another view that creates rationality

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Two extremes, when rational internal dialog is
missing
My feelings and emotions give me suggestions
about what may be real.  I decide whether they
are accurate or not. If they are accurate, I act
on them, if not, I just accept them and let them
go.
My feelings and emotions take over, or tell me
what is real  If I'm feeling down then I'm
doing terrible, if I feel scared, then Im in
danger, etc.
I reject my feelings and emotions, or see them as
my enemy  I need to block them out (or
drugthem away)
Emotional Reasoning, Excess Association
Avoiding Emotions, Dissociation
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One thing that can disrupt internal dialog
Trauma

• When arousal is too great, parts of the mind that
  generate internal dialog evaluating danger can
  shut down (van der Kolk, 2006)
• Which can be good in extreme situation
• Problem is when it doesnt start up again
  afterward
• When experience seems too much to face, long term
  problems can result
• Not just PTSD
• A host of other problems, including psychotic
  symptoms (Read, 2008)

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What is most essential to CBT for Psychosis

• Establishing and maintaining a good relationship
  is more important than any other therapeutic
  activity
• So if anything you are doing interferes with the
  relationship, stop it!
• at least until you find a way to do it that does
  not interfere with the relationship

From the book Cognitive Therapy of
Schizophrenia by Kingdon Turkington, p 43
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General Practices

• Start with befriending, social conversation, and
  relevant self-disclosure
• Avoid jargon but dont talk down to the person
• Walk a middle road between confrontation and
  collusion
• Suspend your disbelief
• Collaborative Empiricism

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Normalizing

• Interpreting psychotic experiences as an
  understandable reaction to events or
  combinations of events
• Reduces the panic and emotional arousal that
  often leads to more psychotic experience
• Normalizing means looking at psychotic
  experiences as existing on a continuum with
  everyday sorts of troublesome experiences and
  confusion
• not categorically different, not insane as
  opposed to sane

From the book Cognitive Therapy of
Schizophrenia by Kingdon Turkington, p 83-05
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Evolving Human Story As I reflect on things, I
can develop stories that meet my emotional needs
while also allowing me to relate well to others
Psychotic story I have to believe this story
for important emotional reasons, even if it gets
me into serious trouble
Psychiatric story my beliefs and experiences
are caused by my disease, for example,
schizophrenia
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One Example of Normalizing Understanding the
Role of Paranoia

• Helps us detect threats
• Can make us feel safer
• they wont slip anything past me
• Gives us someone else to blame

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Developing a formulation

• A formulation is a hypothesis or story about
• what caused problems to develop, and
• what maintains the problems
• The formulation provides
• hope that the problem can be overcome,
• as well as suggestions about how to do that

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Whats causing these weird experiences?
Therapist We can diagnose you with the illness
called schizophrenia because you have these weird
experiences.
Therapist These weird experiences are being
caused by your illness, which is schizophrenia
Client How do you know that I have an illness
called schizophrenia?
Problems occur when a diagnosis is used as an
explanation for the problem
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The traditional explanation is linear and offers
little hope for recovery
From Madness Explained by Richard Bentall
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From Early detection and cognitive therapy for
people at high risk of developing psychosis by
French Morrison
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From the book Working with People at High Risk
of Psychosis, Page 119
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Model of the Renewal Process

• 1. Construct system breaks down
• Due to an impairment or trying to solve a problem
  not solvable within that system
• 2. Temporary suspension of constructs
• Encounter with the transliminal
• 3. Construct restructuring
• If done under stress, formation of rigid beliefs
  with errors are more likely, leading to
• With support and experimentation, formation of
  helpful new vision is more likely

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A Developmental Formulation

• Negative identity defined by others, felt crushed
• Learned how to make up own identity, own world
  view (drugs amplified this)
• Often overdid it, getting grandiose or
  nonsensical, rejecting reason entirely
• Others couldnt understand, often had poor
  relationships
• But
• Found some others who could understand
  appreciate self,
• Felt inspired to make more sense to others,
  resulting in more coherent identity

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Various ways of working with an apparently
delusional belief

• 1. Explore history
• 2. Is it metaphorical?
• 3. Learn to cope better with underlying
  difficulty
• 4. Increase awareness of evidence pro con,
  alternate possible interpretations
• 5. Find ways to live well despite having the
  belief

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Hallucinations

• Cognitive therapists see these as just a persons
  own thoughts or imaginings about something in the
  world,
• temporarily mistaken for perceptions coming in
  directly from the external world
• Cognitive therapists dont try to get rid of
  these, just change the way they are understood
  and related to
• This is consistent with the accepting voices
  approach of the Hearing Voices movement

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How issues with voices resemble issues with
emotions.
My emotions (or voices) give me suggestions about
what may be real.  I decide whether they are
accurate or not. If they are accurate, I act on
them, if not, I just accept them and let them go.
My emotions (or voices) take over or tell me what
is real  If they tell me Im doing terrible
then I am, if they tell me Im in danger then I
am, etc.
I reject my emotions (or voices) or see them as
my enemy  I need to block them out (or
drugthem away)
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Three levels of belief about voices

• 1., Beliefs about content
• 2., Beliefs about power
• 3., Beliefs about identity

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How to change beliefs about voices

• Beliefs about content
• Use steps similar to those used when working with
  automatic thoughts
• Beliefs about power
• Help the person develop better coping tools and
  so increase personal power in relation to the
  voices
• Beliefs about identity
• Explore interpretations, and evidence for
  interpretations, that are less distressing

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Other factors addressed by cognitive therapy for
psychosis

• The emotional arousal that underlies many of the
  more obvious psychotic symptoms
• The sense of defeat that often underlies
  negative symptoms
• Social anxiety and social withdrawal
• Apparently disorganized thinking
• Paranoia, which is seen as on a spectrum with
  everyday anxiety trust issues

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Summary

• Think of psychotic states as having roots in
  normal human concerns
• Join with the client, around exploring what might
  relieve distress
• Suspend your beliefs, instead joining in a
  collaborative empirical exploration with the
  client, drawing out the client's own rational
  process.
• Work out with the client an alternative way of
  making sense of his or her experience, with
  consequences that are less distressing.
• And do this while avoiding "cultural
  imperialism"
• in other words, be open to the idea that your
  proposed alternatives, like the clients own
  original formulation, may be only partially
  correct or helpful.