Cognitive Behavioral Therapy for Psychosis: Concepts and Applications
Cognitive Behavioral Therapy for
Psychosis: A Workshop for
Clinicians
Kim T. Mueser
Center for Psychiatric Rehabilitation
Boston University
(With contributions by Cori Cather, Jen Gottlieb, Eric
Granholm, and Kate Hardy)
REVIEW: 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
EXAMPLE
•
You are sleeping in your ground floor apartment and
you hear scratching on the window. You think
someone might be trying to break into your
apartment.
•
How would you feel in this situation?
•
What might you do?
•
What if you remembered that you let your cat out
before you went to bed, and she didn’t come back
in, so you think maybe it’s your cat at the window?
•
How would you feel? What might you do?
•
Nobody likes me
•
I am a failure
•
People want to hurt me
•
Isolation
•
Avoidance
•
Procrastination
•
Depression
•
Anxiety
•
Fear
THE COGNITIVE-BEHAVIORAL MODEL
CBTp PHILOSOPHY
CBTp PHILOSOPHY
Not so different from CBT for depression
Not so different from CBT for depression
and anxiety, really
and anxiety, really
Human experience and behavior exists on
Human experience and behavior exists on
a continuum
a continuum
Psychotic symptoms (and other
Psychotic symptoms (and other
schizophrenia symptoms) are amenable to
schizophrenia symptoms) are amenable to
cognitive and behavioral interventions
cognitive and behavioral interventions
Reduction of symptoms/distress tied
Reduction of symptoms/distress tied
directly to personal goals
directly to personal goals
THE COGNITIVE-BEHAVIORAL
THE COGNITIVE-BEHAVIORAL
MODEL OF PARANOIA
MODEL OF PARANOIA
•
I
’
m
i
n
d
a
n
g
e
r
•
P
e
o
p
l
e
c
a
n
n
o
t
b
e
t
r
u
s
t
e
d
•
I
’
m
a
n
o
u
t
s
i
d
e
r
•
P
e
o
p
l
e
w
a
n
t
t
o
h
u
r
t
m
e
•
P
a
r
a
n
o
i
a
•
Social Isolation
•
Avoidance
•
Hypervigilence
•
Safety Behaviors
MAIN TENETS OF CBTp
MAIN TENETS OF CBTp
Symptoms are maintained by appraisal and
Symptoms are maintained by appraisal and
behavior
behavior
Distortions are amenable to cognitive and
Distortions are amenable to cognitive and
behavioral approaches
behavioral approaches
Psychotic symptoms (e.g., delusions)
Psychotic symptoms (e.g., delusions)
represent an attempt to make sense of
represent an attempt to make sense of
negative affect
negative affect
WHICH ACT CLIENTS ARE MOST LIKELY
TO BENEFIT FROM CBTp?
•
Persons with persistent psychotic symptoms
•
High levels of distress related to symptoms
•
Preferable if person has some degree of doubt
or is able to consider alternative explanations,
but not absolutely required
•
Can be engaged in talk for 30+ min.
•
Good working relationship with ACT team
member(s)
OVERARCHING GOALS OF CBTp
OVERARCHING GOALS OF CBTp
•
Foster a curious attitude about symptoms
Foster a curious attitude about symptoms
•
Decrease distress
Decrease distress
about
about
symptoms (but not
symptoms (but not
necessarily frequency or intensity of symptoms
necessarily frequency or intensity of symptoms
themselves!)
themselves!)
•
Adopt a
Adopt a
“
“
living with illness
living with illness
”
”
strategy
strategy
•
Improve sense of personal control
Improve sense of personal control
•
Enhance healthy, effective coping with symptoms
Enhance healthy, effective coping with symptoms
•
Improve day-to-day functioning
Improve day-to-day functioning
•
Prevent severe relapse
Prevent severe relapse
STRUCTURE OF CBTp SESSIONS
STRUCTURE OF CBTp SESSIONS
•
Collaborative agenda setting
Collaborative agenda setting
•
Review of previous session
Review of previous session
•
Review of homework
Review of homework
•
Practice new skill in session
Practice new skill in session
•
Assign homework related to new skill area
Assign homework related to new skill area
•
Session review and feedback
Session review and feedback
SELECTIVE CBTp SKILLS
SELECTIVE CBTp SKILLS
•
Engagement and befriending
Engagement and befriending
•
Goal setting
Goal setting
•
Normalization
Normalization
•
Coping strategy enhancement
Coping strategy enhancement
•
Cognitive restructuring
Cognitive restructuring
–
Cognitive distortions
Cognitive distortions
–
Socratic questioning
Socratic questioning
–
Behavioral experiments
Behavioral experiments
ENGAGEMENT AND BEFRIENDING
•
Essential to developing therapeutic
relationship
•
Ongoing process throughout therapy
•
May require increased amounts of
befriending depending on symptoms
–
Paranoia
–
Hallucinations
–
Severe negative symptoms
BEFRIENDING (Cont’d)
•
Befriending
-Focus on neutral non threatening topics
-No active formulation or treatment
-Non-confrontational
-Empathic
-Supportive
-Accepting
-Non-colluding
•
Assertive engagement
COMMON ENGAGEMENT
COMMON ENGAGEMENT
DIFFICULTIES IN CBTp
DIFFICULTIES IN CBTp
•
Poor session attendance
Poor session attendance
•
Lack of enthusiasm for treatment
Lack of enthusiasm for treatment
•
Paranoia or low disclosure at outset
Paranoia or low disclosure at outset
•
Difficulty formulating problems or goals
Difficulty formulating problems or goals
SOLUTIONS:
SOLUTIONS:
ASSESS UNDERLYING CAUSES
ASSESS UNDERLYING CAUSES
•
Organizational difficulties: problem-solve
Organizational difficulties: problem-solve
solutions
solutions
•
Are you working on what is important to the
Are you working on what is important to the
client???
client???
•
Is low enthusiasm simply negative
Is low enthusiasm simply negative
symptoms?
symptoms?
•
Take it slow, build trust, get to know the
Take it slow, build trust, get to know the
person, seek to align with their goals or
person, seek to align with their goals or
interests
interests
ASSESSMENT DOMAINS
ASSESSMENT DOMAINS
Negative Symptoms
Reduced emotional
expressiveness
Poverty of speech
Loss of motivation
Decreased activity
Social withdrawal
Cognitive Deficits
Attention
Memory
Executive functions
Insight
Comorbid Conditions
Mood
Substance abuse
Anxiety
Medical Illness
Quality of Life
Work/School/Recreation
Interpersonal relationships
Physical health/self-care
Positive Symptoms
Delusions
Hallucinations
Disorganized thoughts
AND…
AND…
•
Suicidality/homicidality
Suicidality/homicidality
•
Short and longer term life goals
Short and longer term life goals
•
Values
Values
•
Understanding of psychosis and associated
Understanding of psychosis and associated
symptoms
symptoms
•
Medication adherence
Medication adherence
DEVELOPING A PROBLEM/GOAL LIST
DEVELOPING A PROBLEM/GOAL LIST
•
Collaboration is key
Collaboration is key
•
Elicit
Elicit
problem areas
problem areas
by discussing what is
by discussing what is
distressing to the person and what
distressing to the person and what
interferes with the goals or desires
interferes with the goals or desires
•
Assess what is most important to guide
Assess what is most important to guide
goal development
goal development
•
Shows the client you are listening and
Shows the client you are listening and
creates a sense that difficulties are
creates a sense that difficulties are
contained rather than infinite
contained rather than infinite
DEVELOP A PROBLEM/GOAL LIST
DEVELOP A PROBLEM/GOAL LIST
(Cont
(Cont
’
’
d)
d)
•
Brainstorm and be broad initially, then focus
Brainstorm and be broad initially, then focus
and become more specific
and become more specific
•
Prioritize and maintain a focus throughout
Prioritize and maintain a focus throughout
work with person
work with person
•
Include at least one goal related to a
Include at least one goal related to a
psychotic symptom
psychotic symptom
•
Other goals may be functional goals related
Other goals may be functional goals related
to interference from psychosis or simply life
to interference from psychosis or simply life
goals
goals
SAMPLE PROBLEM LIST
SAMPLE PROBLEM LIST
1.
“
“
Neighbors are using wireless
Neighbors are using wireless
technology against me.
technology against me.
”
”
2.
“
“
The voices keep me from getting a
The voices keep me from getting a
job.
job.
”
”
3.
“
“
I don
I don
’
’
t have anything to do all day.
t have anything to do all day.
”
”
4.
“I used to drive and now am worried
“I used to drive and now am worried
about doing anything other than walking
about doing anything other than walking
around the block with my mom.”
around the block with my mom.”
5.
“I’m confused about these experiences.”
“I’m confused about these experiences.”
B
r
y
a
n
t
SAMPLE PROBLEM LIST
SAMPLE PROBLEM LIST
1.
“
“
Neighbors are watching me and informing
Neighbors are watching me and informing
the police about me.
the police about me.
”
”
2.
“
“
I am being controlled by their instructions.
I am being controlled by their instructions.
”
”
3.
“
“
I feel like my family does not care about
I feel like my family does not care about
me.
me.
”
”
4.
“I need to lose weight.”
“I need to lose weight.”
C
h
a
r
l
o
t
t
e
NORMALIZATION
•
CBT is inherently normalizing
–
We all experience negative thoughts
–
We all engage in unhelpful thinking
–
We all use coping strategies that aren’t
always the most healthy choices
•
Allows for normalizing of psychotic symptoms as
well
PSYCHOSIS EXISTS ON A CONTINUUM
•
Stress
•
Drugs
•
Trauma
•
Life experiences
•
Sleep deprivation
NORMALIZATION OF PSYCHOTIC SYMPTOMS
•
“Normalization is the antidote to stigma”
–
Avoid catastrophizing
•
Mental Illness is a common experience (1 in 4 people)
•
Psychosis can affect anyone regardless of age,
ethnicity, gender, SES
•
Large number of people can overcome symptoms
•
Symptoms may be viewed positively in different
cultures
•
Normalizing experiences – not dismissing them
•
Check in how the information is received
(invalidating?)
NORMALIZING: HOW
•
Encourage people to research and read personal
recovery stories
–
Elyn Saks
–
John Nash
–
Eleanor Longden
–
Rufus May
–
Develop library of recovery stories
NORMALIZING: HOW
•
Research prevalence of symptoms (depression, hearing voices, paranoia
etc.)
•
15-20% population experience frequent paranoid thoughts without
significant distress
•
3-5% population have more severe paranoia (Freeman, 2006)
•
5% of population hear voices (Tien 1991)
•
People hear voices without seeking mental health services (Romme
& Escher 1989)
•
9% people hold delusional beliefs (van Os, 2000)
•
Common to see or hear loved one following bereavement (Grimby
1993)
•
Connect with other people experiencing psychosis
–
Intervoice
–
Psycope.co.uk
–
Paranoia.com
VIDEO DEMONSTRATION OF
NORMALIZATION
RATIONALE FOR COPING
RATIONALE FOR COPING
STRATEGY ENHANCEMENT
STRATEGY ENHANCEMENT
•
Focus on distressing symptoms
Focus on distressing symptoms
•
Does not require insight into hallucinations or
Does not require insight into hallucinations or
delusions
delusions
•
Use analogies to other distressing
Use analogies to other distressing
experiences (e.g., migraine headaches,
experiences (e.g., migraine headaches,
bullying)
bullying)
•
Express empathy that this has been difficult
Express empathy that this has been difficult
and client has done best he/she can
and client has done best he/she can
•
Express optimism that together you can
Express optimism that together you can
improve coping
improve coping
ASSESS CURRENT AND PAST
ASSESS CURRENT AND PAST
COPING RESPONSES
COPING RESPONSES
•
Evaluate behavioral, cognitive, affective
Evaluate behavioral, cognitive, affective
strategies person has used in the past
strategies person has used in the past
•
Categorize as “helpful” “unhelpful” and
Categorize as “helpful” “unhelpful” and
“unknown”
“unknown”
•
Aggressive engagement and extreme
Aggressive engagement and extreme
avoidance are usually unhelpful strategies
avoidance are usually unhelpful strategies
•
Assign a coping monitoring log
Assign a coping monitoring log
•
Example (next page) of helpful and not
Example (next page) of helpful and not
helpful coping strategies for hallucinations
helpful coping strategies for hallucinations
HELPFUL
HELPFUL
•
Studying for my exam
Studying for my exam
•
Watching movies
Watching movies
•
Telling myself that I can
Telling myself that I can
handle this
handle this
•
Going for a walk with mom
Going for a walk with mom
•
Making a list of my good
Making a list of my good
qualities
qualities
•
“I am a good employee and
“I am a good employee and
will be an asset to any
will be an asset to any
organization of which I am a
organization of which I am a
part”
part”
NOT HELPFUL
NOT HELPFUL
•
Yelling back to voices
Yelling back to voices
•
Calling the police
Calling the police
•
Researching wireless
Researching wireless
technology
technology
•
Trying to convince my
Trying to convince my
dad to believe me
dad to believe me
•
Believing what they say
Believing what they say
•
Losing hope about my
Losing hope about my
future
future
B
r
y
a
n
t
VOICES: COPING LOG
VOICES: COPING LOG
C
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o
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BEHAVIORAL COPING
BEHAVIORAL COPING
STRATEGIES
STRATEGIES
•
Listen to music or other things
Listen to music or other things
•
Change your location
Change your location
•
Talk with someone, such as trusted other,
Talk with someone, such as trusted other,
friend, etc.
friend, etc.
•
Listen to a relaxation tape or do a relaxation
Listen to a relaxation tape or do a relaxation
exercise
exercise
•
Take a shower
Take a shower
•
Exercise or go for a walk
Exercise or go for a walk
•
Do a hobby or other activity
Do a hobby or other activity
COGNITIVE COPING STRATEGIES
COGNITIVE COPING STRATEGIES
•
Keep a diary to identify triggers, content of
Keep a diary to identify triggers, content of
the hallucination and associated thoughts
the hallucination and associated thoughts
•
Focus in on the experience and use distress
Focus in on the experience and use distress
tolerance skills
tolerance skills
•
Use positive self-talk or prayer
Use positive self-talk or prayer
•
Conduct a pro/con analysis (Pay-off Matrix)
Conduct a pro/con analysis (Pay-off Matrix)
with command hallucinations and make your
with command hallucinations and make your
own decision about what to do
own decision about what to do
•
Use acceptance-based strategies that don’t
Use acceptance-based strategies that don’t
actively attempt to suppress hallucinations
actively attempt to suppress hallucinations
ACCEPTANCE AND COMMITMENT
ACCEPTANCE AND COMMITMENT
THERAPY: THE OTHER ACT
THERAPY: THE OTHER ACT
•
Developed by Stephen Hayes, related to CBTp, but
Developed by Stephen Hayes, related to CBTp, but
not the same
not the same
•
Agrees with CBT that thoughts are the cause of much
Agrees with CBT that thoughts are the cause of much
misery, but disagrees that solution is to modify the
misery, but disagrees that solution is to modify the
thoughts
thoughts
•
Acceptance = understanding of the essential
Acceptance = understanding of the essential
uncontrollability of thoughts
uncontrollability of thoughts
•
Commitment = commitment to one’s values and
Commitment = commitment to one’s values and
goals, and behavior aligned towards them
goals, and behavior aligned towards them
•
Suppression of thoughts ineffective
Suppression of thoughts ineffective
•
Alternative: “just notice” thoughts, and get on with
Alternative: “just notice” thoughts, and get on with
one’s life
one’s life
•
Example: “Thanking” one’s brain for the hallucination
Example: “Thanking” one’s brain for the hallucination
COGNITIVE COPING
COGNITIVE COPING
STRATEGIES (Cont
STRATEGIES (Cont
’
’
d)
d)
•
Hallucination scheduling (permit for
Hallucination scheduling (permit for
period of time during day like worry
period of time during day like worry
scheduling)
scheduling)
•
Review reattribution ideas that have
Review reattribution ideas that have
been helpful
been helpful
VIDEO DEMONSTRATION OF
UNDERSTANDING VOICES
COGNITIVE RESTRUCTURING
•
Teach clients the connection between
thoughts and feelings
•
Explain that the thoughts people have
are often
“
automatic
”
and are often
related to past experiences (e.g.,
traumatic) and self-perceptions
•
Facilitate the examination of evidence
supporting thoughts and beliefs underlying
strong negative feelings
COGNITIVE RESTRUCTURING (Cont’d)
•
Help clients challenge and modify upsetting
thoughts and beliefs that are not supported by
evidence by:
–
Socratic questioning
–
Exploring alternative beliefs
–
Behavioral experiments
–
Teaching how to recognize distorted thinking styles
CR TARGETS IN CBTp
CR TARGETS IN CBTp
•
Accuracy of distressing belief
Accuracy of distressing belief
•
Utility of holding onto belief
Utility of holding onto belief
•
Beliefs about the power and controllability of
Beliefs about the power and controllability of
voices/persecutors
voices/persecutors
•
Negative core beliefs about self, other
Negative core beliefs about self, other
’
’
s
s
perceptions of self, future
perceptions of self, future
•
Self-stigmatized beliefs related to illness
Self-stigmatized beliefs related to illness
•
Beliefs about medications and treatment
Beliefs about medications and treatment
SOCRATIC QUESTIONING
SOCRATIC QUESTIONING
OVERVIEW
OVERVIEW
-Build rapport, engagement
-Build rapport, engagement
-Can be an MI technique
-Can be an MI technique
-Explore how person understand an event, voice,
-Explore how person understand an event, voice,
thought, etc.
thought, etc.
-Explore possible consequences of staying
-Explore possible consequences of staying
with particular maladaptive thoughts or behaviors
with particular maladaptive thoughts or behaviors
-Help clients to question own inaccurate or
-Help clients to question own inaccurate or
distressing assumptions, beliefs and behaviors
distressing assumptions, beliefs and behaviors
-Help clients arrive at a new view of the situation
-Help clients arrive at a new view of the situation
that is more in line with evidence
that is more in line with evidence
SOCRATIC QUESTIONING STYLE
SOCRATIC QUESTIONING STYLE
•
Colombo-like style: freely admit confusion
Colombo-like style: freely admit confusion
when trying to understand something, ask
when trying to understand something, ask
for client’s help in resolving confusion
for client’s help in resolving confusion
•
Ask, don
Ask, don
’
’
t tell
t tell
•
Probe questions
Probe questions
•
Gentle, non-judgmental curious style –
Gentle, non-judgmental curious style –
don
don
’
’
t interrogate!
t interrogate!
•
Foster client
Foster client
’
’
s curiosity too
s curiosity too
HOW TO: SOCRATIC
HOW TO: SOCRATIC
QUESTIONING
QUESTIONING
•
Explore
Explore
meaning
meaning
client attaches to a specific event,
client attaches to a specific event,
voice, thought…
voice, thought…
“
“
What does it say about you that you are being watched by
What does it say about you that you are being watched by
the government? If this were not the case, what would
the government? If this were not the case, what would
that say about you as a person?
that say about you as a person?
”
”
•
Explore possible
Explore possible
consequences
consequences
of staying with particular
of staying with particular
maladaptive thoughts or behaviors
maladaptive thoughts or behaviors
“
“
So, what happens if you continue to yell at your voices in
So, what happens if you continue to yell at your voices in
public?
public?
”
”
“
“
You spend a lot of time thinking about the idea that you
You spend a lot of time thinking about the idea that you
need to develop superpowers to read others minds in
need to develop superpowers to read others minds in
order to be happy. I wonder if that gets in the way of you
order to be happy. I wonder if that gets in the way of you
pursuing other meaningful things in life?
pursuing other meaningful things in life?
”
”
H
H
O
O
W
W
T
T
O
O
:
:
S
S
O
O
C
C
R
R
A
A
T
T
I
I
C
C
Q
Q
U
U
E
E
S
S
T
T
I
I
O
O
N
N
I
I
N
N
G
G
(
(
C
C
o
o
n
n
t
t
’
’
d
d
)
)
•
What do you make of
What do you make of
the fact that your brother says he
the fact that your brother says he
can
can
’
’
t hear what you hear?
t hear what you hear?
•
I wonder if it might be important
I wonder if it might be important
for us to talk more about
for us to talk more about
your belief that you are adopted, since it is causing so much
your belief that you are adopted, since it is causing so much
distress?
distress?
•
I
I
’
’
m curious:
m curious:
what sorts of things got you thinking that your
what sorts of things got you thinking that your
co-workers were poisoning your lunch?
co-workers were poisoning your lunch?
•
You’
You’
ve mentioned that you are being terrorized by people
ve mentioned that you are being terrorized by people
on the street.
on the street.
What
What
’
’
s your sense of why that might be?
s your sense of why that might be?
•
Help me understand
Help me understand
a bit more about how that brain
a bit more about how that brain
implant device works.
implant device works.
EXPLORING DYSFUNCTIONAL
EXPLORING DYSFUNCTIONAL
BELIEFS ABOUT VOICES
BELIEFS ABOUT VOICES
EXPLORING BELIEFS ABOUT VOICES:
EXPLORING BELIEFS ABOUT VOICES:
HELPFUL PROBE QUESTIONS
HELPFUL PROBE QUESTIONS
Control
Control
How much control do you have over the voices?
How much control do you have over the voices?
Are there some things the voices told you to do
Are there some things the voices told you to do
where you drew the line and refused?
where you drew the line and refused?
Power
Power
Who is more powerful, you or the voices?
Who is more powerful, you or the voices?
Do the voices make empty threats?
Do the voices make empty threats?
EXPLORING BELIEFS ABOUT VOICES:
EXPLORING BELIEFS ABOUT VOICES:
HELPFUL PROBE QUESTIONS
HELPFUL PROBE QUESTIONS
(Cont
(Cont
’
’
d)
d)
Trustworthiness
Trustworthiness
Do the voices ever provide contradictory
Do the voices ever provide contradictory
information? Have they ever lied? Can they
information? Have they ever lied? Can they
always be trusted?
always be trusted?
Usefulness of Listening/Complying
Usefulness of Listening/Complying
What important information has the voices given
What important information has the voices given
you over the years?
you over the years?
Do the voices ever give you misinformation or lead
Do the voices ever give you misinformation or lead
you on a wild-goose chase?
you on a wild-goose chase?
EXPLORING BELIEFS ABOUT
EXPLORING BELIEFS ABOUT
VOICES: HELPFUL PROBE
VOICES: HELPFUL PROBE
QUESTIONS (Cont
QUESTIONS (Cont
’
’
d)
d)
Malevolence
Malevolence
•
Have the voices ever been helpful or kind?
Have the voices ever been helpful or kind?
•
Is there anything you might miss about the voices
Is there anything you might miss about the voices
if they were gone?
if they were gone?
OVERVIEW: EXPLORING
OVERVIEW: EXPLORING
ALTERNATIVE BELIEFS
ALTERNATIVE BELIEFS
•
Teach cognitive flexibility as a skill
Teach cognitive flexibility as a skill
•
Pre-cursor to CR
Pre-cursor to CR
•
Begin with coaching around generating
Begin with coaching around generating
alternative beliefs for everyday scenarios
alternative beliefs for everyday scenarios
•
Then progress to scenarios that are tailored
Then progress to scenarios that are tailored
to the individual’s delusional or paranoid
to the individual’s delusional or paranoid
beliefs
beliefs
E
E
X
X
P
P
L
L
O
O
R
R
I
I
N
N
G
G
A
A
L
L
T
T
E
E
R
R
N
N
A
A
T
T
I
I
V
V
E
E
B
B
E
E
L
L
I
I
E
E
F
F
S
S
(
(
C
C
o
o
n
n
t
t
’
’
d
d
)
)
•
“
“
Behavioral scaffolding
Behavioral scaffolding
”
”
•
Start with identified alternative responses to situation, move
Start with identified alternative responses to situation, move
toward coaching of additional responses, then to
toward coaching of additional responses, then to
independence with the exercise items
independence with the exercise items
•
Helpful probe questions:
Helpful probe questions:
“
“
What
What
’
’
s another possible explanation for why this may have
s another possible explanation for why this may have
happened?
happened?
”
”
“
“
What factors related to____(the situation/the way the world
What factors related to____(the situation/the way the world
works/the person involved in the scenario/you) may have
works/the person involved in the scenario/you) may have
caused or contributed to this happening?
caused or contributed to this happening?
”
”
BASED ON THE COGNITIVE
BASED ON THE COGNITIVE
MODEL
MODEL
“
“
S
S
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”
”
It
It
’
’
s the mafia
s the mafia
Anxious, scared
Anxious, scared
It was a wrong number
It was a wrong number
Calm
Calm
It was a telemarketer
It was a telemarketer
Slightly Annoyed
Slightly Annoyed
TIPS ON ALTERNATIVE BELIEFS
TIPS ON ALTERNATIVE BELIEFS
EXERCISE
EXERCISE
•
Coach remains completely neutral about
Coach remains completely neutral about
explanations
explanations
•
Goal is
Goal is
not
not
to come to the “correct”
to come to the “correct”
appraisal, but rather to acknowledge that
appraisal, but rather to acknowledge that
most of the time we do not really know why
most of the time we do not really know why
something happens the way it does
something happens the way it does
•
Help client
Help client
“
“
loosen up
loosen up
”
”
their thinking rigidity
their thinking rigidity
and reduce
and reduce
“
“
jumping to conclusions
jumping to conclusions
”
”
NEUTRAL ITEM:
NEUTRAL ITEM:
“
“
Clerk at Dunkin Donuts gives
Clerk at Dunkin Donuts gives
you hot coffee when you ordered iced coffee.
you hot coffee when you ordered iced coffee.
”
”
•
She didn’t hear me correctly.
She didn’t hear me correctly.
•
The ice machine was broken.
The ice machine was broken.
•
She is trying to send me a message that the
She is trying to send me a message that the
demons are coming for me.
demons are coming for me.
•
She is tired because she is sick so she her brain
She is tired because she is sick so she her brain
is not working well.
is not working well.
•
She has her manager watching her today and
She has her manager watching her today and
she is nervous which is making her make
she is nervous which is making her make
mistakes.
mistakes.
•
I thought I said iced coffee, but I actually said hot
I thought I said iced coffee, but I actually said hot
coffee.
coffee.
INDIVIDUALIZED ITEM:
INDIVIDUALIZED ITEM:
“
“
The newscaster
The newscaster
looks right at the camera and says
looks right at the camera and says
“
“
Dan.
Dan.
”
”
•
He is talking to me because I can forecast the
He is talking to me because I can forecast the
weather.
weather.
•
He is talking about someone famous named Dan.
He is talking about someone famous named Dan.
•
He is calling the camera man named Dan and it
He is calling the camera man named Dan and it
wasn’t supposed to be caught on tape.
wasn’t supposed to be caught on tape.
•
Someone in the other room called my name and I
Someone in the other room called my name and I
misheard it as coming from the TV.
misheard it as coming from the TV.
•
He was saying a different word like Taliban that
He was saying a different word like Taliban that
sounded to me like Dan.
sounded to me like Dan.
GENERATING ALTERNATIVE
GENERATING ALTERNATIVE
BELIEFS - JULIE
BELIEFS - JULIE
“
“
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”
”
He is my biological father, there to send me that
He is my biological father, there to send me that
message
message
Anxious, scared, sad
Anxious, scared, sad
He was a relative of another patient who visited a
He was a relative of another patient who visited a
lot
lot
Calm
Calm
He was a case manager who had a few
He was a case manager who had a few
hospitalized patients on his caseload
hospitalized patients on his caseload
Calm
Calm
EXAMPLE: IN-SESSION CBT
EXAMPLE: IN-SESSION CBT
TECHNIQUES TO ADDRESS PARANOIA
TECHNIQUES TO ADDRESS PARANOIA
C
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”
”
IN-SESSION CBT TECHNIQUES TO
IN-SESSION CBT TECHNIQUES TO
ADDRESS PARANOIA (Cont
ADDRESS PARANOIA (Cont
’
’
d)
d)
T
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:
:
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”
BEHAVIORAL EXPERIMENTS
BEHAVIORAL EXPERIMENTS
•
Goal is to get additional information about a belief
Goal is to get additional information about a belief
in a “scientific,” mutually agreed upon fashion
in a “scientific,” mutually agreed upon fashion
•
Frequently used to examine “safety behaviors”
Frequently used to examine “safety behaviors”
and then to systematically move toward reducing
and then to systematically move toward reducing
or dropping them
or dropping them
•
Re-evaluate client
Re-evaluate client
’
’
s level of conviction, distress,
s level of conviction, distress,
preoccupation following each experiment
preoccupation following each experiment
•
Julie (fear of people spying):
Julie (fear of people spying):
“
“
Keep shades up
Keep shades up
between hours of 1-2pm each day and evaluate
between hours of 1-2pm each day and evaluate
mood, thoughts, and consequences
mood, thoughts, and consequences
”
”
BEHAVIORAL EXPERIMENTS (Cont
BEHAVIORAL EXPERIMENTS (Cont
’
’
d)
d)
In vivo, outside of the office
In vivo, outside of the office
Sample experiment (“Other people can read my
Sample experiment (“Other people can read my
mind”)
mind”)
Prediction: all people on campus will stare at me
Prediction: all people on campus will stare at me
and laugh at me if I think a sexual thought
and laugh at me if I think a sexual thought
Confirmed if: they look at me and begin
Confirmed if: they look at me and begin
laughing within 3 seconds
laughing within 3 seconds
Procedure:
Procedure:
Find a
Find a
“
“
high anxiety
high anxiety
”
”
(high density) spot on
(high density) spot on
campus
campus
Monitor reactions of people
Monitor reactions of people
Debrief with therapist
Debrief with therapist
VIDEO DEMONSTRATION OF
BEHAVIORAL EXPERIMENTS
TEACHING HOW TO RECOGNIZE
COGNITIVE DISTORTIONS
•
Easily learned strategy for dealing with negative
feelings
•
As client’s skill at catching and changing
cognitive distortions in everyday situations
increases, focus gradually shifts to psychotic
symptoms
•
Begin with discussion of how thoughts in a
situation affect feelings (and behaviors), and
not all thoughts are equally accurate
RECOGNITION OF COGNITIVE
DISTORTIONS (Cont’d)
•
Normalize cognitive distortions as common styles of
inaccurate thinking that everyone engages in to some
extent
•
Explain how correcting cognitive distortions can reduce
negative feelings associated with them
•
For each type of distortion, briefly explain it, try to
elicit a personal example from client
•
When example elicited, explore why it is a distortion
(i.e., why inaccurate)
•
Then, identify a more accurate thought, and discuss
differences in feelings related to the two thoughts
COMMON COGNITIVE DISTORTIONS
COMMON COGNITIVE DISTORTIONS
(AKA
(AKA
“
“
COMMON STYLES OF THINKING
COMMON STYLES OF THINKING
”
”
)
)
•
A
A
l
l
l
l
o
o
r
r
N
N
o
o
t
t
h
h
i
i
n
n
g
g
T
T
h
h
i
i
n
n
k
k
i
i
n
n
g
g
–
“
“
If I wake up with some symptoms, my week will be
If I wake up with some symptoms, my week will be
ruined.
ruined.
”
”
•
“
“
M
M
u
u
s
s
t
t
,
,
”
”
“
“
s
s
h
h
o
o
u
u
l
l
d
d
,
,
”
”
o
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r
r
“
“
n
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e
v
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e
r
r
”
”
s
s
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a
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m
m
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e
n
n
t
t
s
s
–
“
“
I
I
s
s
h
h
o
o
u
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l
d
d
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m
m
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n
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s
s
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e
.
.
”
”
•
O
O
v
v
e
e
r
r
g
g
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e
n
n
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e
r
r
a
a
l
l
i
i
z
z
a
a
t
t
i
i
o
o
n
n
–
“
“
The receptionist at the clinic didn’t smile at me today:
The receptionist at the clinic didn’t smile at me today:
that means everyone hates me there and wants me to
that means everyone hates me there and wants me to
go into the hospital.
go into the hospital.
”
”
•
C
C
a
a
t
t
a
a
s
s
t
t
r
r
o
o
p
p
h
h
i
i
z
z
i
i
n
n
g
g
–
“
“
The man on the train looked at me sideways when I
The man on the train looked at me sideways when I
got on; he is going to try to stab me when I get to my
got on; he is going to try to stab me when I get to my
stop.
stop.
”
”
COMMON COGNITIVE DISTORTIONS (Cont’d)
COMMON COGNITIVE DISTORTIONS (Cont’d)
•
M
M
i
i
n
n
d
d
-
-
r
r
e
e
a
a
d
d
i
i
n
n
g
g
–
“
“
My neighbor said
My neighbor said
‘
‘
cold outside today
cold outside today
’
’
to me; she is
to me; she is
trying to send me the message that they will break into
trying to send me the message that they will break into
my apartment
my apartment
and implant the device.”
and implant the device.”
•
E
E
m
m
o
o
t
t
i
i
o
o
n
n
a
a
l
l
r
r
e
e
a
a
s
s
o
o
n
n
i
i
n
n
g
g
–
“
“
It
It
felt
felt
like the guy on the street was sending me
like the guy on the street was sending me
messages; therefore I am in danger.
messages; therefore I am in danger.
”
”
•
M
M
e
e
n
n
t
t
a
a
l
l
F
F
i
i
l
l
t
t
e
e
r
r
/
/
D
D
i
i
s
s
q
q
u
u
a
a
l
l
i
i
f
f
y
y
i
i
n
n
g
g
t
t
h
h
e
e
P
P
o
o
s
s
i
i
t
t
i
i
v
v
e
e
–
“
“
I did have a good meeting with the supported
I did have a good meeting with the supported
employment staff, they probably just felt bad for me
employment staff, they probably just felt bad for me
though.
though.
”
”
•
P
P
e
e
r
r
s
s
o
o
n
n
a
a
l
l
i
i
z
z
a
a
t
t
i
i
o
o
n
n
–
“
“
Clerk walked quickly down the aisle when he passed
Clerk walked quickly down the aisle when he passed
me indicating that he knows who I am and what I did.
me indicating that he knows who I am and what I did.
”
”
Explore the foundational principles of Cognitive Behavioral Therapy (CBT) for psychosis, emphasizing how thoughts influence feelings and behaviors. Gain insights into the cognitive-behavioral model of paranoia and learn about the main tenets of CBTp. Discover how CBTp can effectively address psychotic symptoms by targeting cognitive distortions and maladaptive behaviors, tying symptom reduction to personal goals.
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Presentation Transcript
Cognitive Behavioral Therapy for Psychosis: A Workshop for Clinicians Kim T. Mueser Center for Psychiatric Rehabilitation Boston University (With contributions by Cori Cather, Jen Gottlieb, Eric Granholm, and Kate Hardy)
REVIEW: 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
EXAMPLE You are sleeping in your ground floor apartment and you hear scratching on the window. You think someone might be trying to break into your apartment. How would you feel in this situation? What might you do? What if you remembered that you let your cat out before you went to bed, and she didn t come back in, so you think maybe it s your cat at the window? How would you feel? What might you do?
THE COGNITIVE-BEHAVIORAL MODEL Nobody likes me I am a failure Thoughts People want to hurt me Mood Behavior Isolation Depression Avoidance Anxiety Procrastination Fear
CBTp PHILOSOPHY Not so different from CBT for depression and anxiety, really 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
THE COGNITIVE-BEHAVIORAL MODEL OF PARANOIA I m in danger People cannot be trusted I m an outsider Social Isolation Avoidance Hypervigilence Safety Behaviors People want to hurt me Thoughts Paranoia Emotions Behavior
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
WHICH ACT CLIENTS ARE MOST LIKELY TO BENEFIT FROM CBTp? Persons with persistent psychotic symptoms High levels of distress related to symptoms Preferable if person has some degree of doubt or is able to consider alternative explanations, but not absolutely required Can be engaged in talk for 30+ min. Good working relationship with ACT team member(s)
OVERARCHING GOALS OF CBTp Foster a curious attitude about symptoms Decrease distress about symptoms (but not necessarily frequency or intensity of symptoms themselves!) Adopt a living with illness strategy Improve sense of personal control Enhance healthy, effective coping with symptoms Improve day-to-day functioning Prevent severe relapse
STRUCTURE OF CBTp SESSIONS Collaborative agenda setting Review of previous session Review of homework Practice new skill in session Assign homework related to new skill area Session review and feedback
SELECTIVE CBTp SKILLS Engagement and befriending Goal setting Normalization Coping strategy enhancement Cognitive restructuring Cognitive distortions Socratic questioning Behavioral experiments
ENGAGEMENT AND BEFRIENDING Essential to developing therapeutic relationship Ongoing process throughout therapy May require increased amounts of befriending depending on symptoms Paranoia Hallucinations Severe negative symptoms
BEFRIENDING (Contd) Befriending -Focus on neutral non threatening topics -No active formulation or treatment -Non-confrontational -Empathic -Supportive -Accepting -Non-colluding Assertive engagement
COMMON ENGAGEMENT DIFFICULTIES IN CBTp Poor session attendance Lack of enthusiasm for treatment Paranoia or low disclosure at outset Difficulty formulating problems or goals
SOLUTIONS: ASSESS UNDERLYING CAUSES Organizational difficulties: problem-solve solutions Are you working on what is important to the client??? Is low enthusiasm simply negative symptoms? Take it slow, build trust, get to know the person, seek to align with their goals or interests
ASSESSMENT DOMAINS Positive Symptoms Delusions Hallucinations Disorganized thoughts Negative Symptoms Reduced emotional expressiveness Poverty of speech Loss of motivation Decreased activity Social withdrawal Quality of Life Work/School/Recreation Interpersonal relationships Physical health/self-care Cognitive Deficits Attention Memory Executive functions Insight Comorbid Conditions Mood Substance abuse Anxiety Medical Illness
AND Suicidality/homicidality Short and longer term life goals Values Understanding of psychosis and associated symptoms Medication adherence
DEVELOPING A PROBLEM/GOAL LIST Collaboration is key Elicit problem areas by discussing what is distressing to the person and what interferes with the goals or desires Assess what is most important to guide goal development Shows the client you are listening and creates a sense that difficulties are contained rather than infinite
DEVELOP A PROBLEM/GOAL LIST (Cont d) Brainstorm and be broad initially, then focus and become more specific Prioritize and maintain a focus throughout work with person Include at least one goal related to a psychotic symptom Other goals may be functional goals related to interference from psychosis or simply life goals
Bryant SAMPLE PROBLEM LIST 1. Neighbors are using wireless technology against me. 2. The voices keep me from getting a job. 3. I don t have anything to do all day. 4. I used to drive and now am worried about doing anything other than walking around the block with my mom. 5. I m confused about these experiences.
Charlotte SAMPLE PROBLEM LIST 1. Neighbors are watching me and informing the police about me. 2. I am being controlled by their instructions. 3. I feel like my family does not care about me. 4. I need to lose weight.
NORMALIZATION CBT is inherently normalizing We all experience negative thoughts We all engage in unhelpful thinking We all use coping strategies that aren t always the most healthy choices Allows for normalizing of psychotic symptoms as well
PSYCHOSIS EXISTS ON A CONTINUUM Stress Drugs Trauma Life experiences Sleep deprivation Psychosis No psychosis
NORMALIZATION OF PSYCHOTIC SYMPTOMS Normalization is the antidote to stigma Avoid catastrophizing Mental Illness is a common experience (1 in 4 people) Psychosis can affect anyone regardless of age, ethnicity, gender, SES Large number of people can overcome symptoms Symptoms may be viewed positively in different cultures Normalizing experiences not dismissing them Check in how the information is received (invalidating?)
NORMALIZING: HOW Encourage people to research and read personal recovery stories Elyn Saks John Nash Eleanor Longden Rufus May Develop library of recovery stories
NORMALIZING: HOW Research prevalence of symptoms (depression, hearing voices, paranoia etc.) 15-20% population experience frequent paranoid thoughts without significant distress 3-5% population have more severe paranoia (Freeman, 2006) 5% of population hear voices (Tien 1991) People hear voices without seeking mental health services (Romme & Escher 1989) 9% people hold delusional beliefs (van Os, 2000) Common to see or hear loved one following bereavement (Grimby 1993) Connect with other people experiencing psychosis Intervoice Psycope.co.uk Paranoia.com
VIDEO DEMONSTRATION OF NORMALIZATION
RATIONALE FOR COPING STRATEGY ENHANCEMENT Focus on distressing symptoms Does not require insight into hallucinations or delusions Use analogies to other distressing experiences (e.g., migraine headaches, bullying) Express empathy that this has been difficult and client has done best he/she can Express optimism that together you can improve coping
ASSESS CURRENT AND PAST COPING RESPONSES Evaluate behavioral, cognitive, affective strategies person has used in the past Categorize as helpful unhelpful and unknown Aggressive engagement and extreme avoidance are usually unhelpful strategies Assign a coping monitoring log Example (next page) of helpful and not helpful coping strategies for hallucinations
Bryant HELPFUL Studying for my exam Watching movies Telling myself that I can handle this Going for a walk with mom Making a list of my good qualities I am a good employee and will be an asset to any organization of which I am a part NOT HELPFUL Yelling back to voices Calling the police Researching wireless technology Trying to convince my dad to believe me Believing what they say Losing hope about my future
Charlotte VOICES: COPING LOG Situation What did How did you respond? Went to bed at 4pm How effective? you hear? Home thinking about watching TV Not at all A little Some A lot She is home.
BEHAVIORAL COPING STRATEGIES Listen to music or other things Change your location Talk with someone, such as trusted other, friend, etc. Listen to a relaxation tape or do a relaxation exercise Take a shower Exercise or go for a walk Do a hobby or other activity
COGNITIVE COPING STRATEGIES Keep a diary to identify triggers, content of the hallucination and associated thoughts Focus in on the experience and use distress tolerance skills Use positive self-talk or prayer Conduct a pro/con analysis (Pay-off Matrix) with command hallucinations and make your own decision about what to do Use acceptance-based strategies that don t actively attempt to suppress hallucinations
ACCEPTANCE AND COMMITMENT THERAPY: THE OTHER ACT Developed by Stephen Hayes, related to CBTp, but not the same Agrees with CBT that thoughts are the cause of much misery, but disagrees that solution is to modify the thoughts Acceptance = understanding of the essential uncontrollability of thoughts Commitment = commitment to one s values and goals, and behavior aligned towards them Suppression of thoughts ineffective Alternative: just notice thoughts, and get on with one s life Example: Thanking one s brain for the hallucination
COGNITIVE COPING STRATEGIES (Cont d) Hallucination scheduling (permit for period of time during day like worry scheduling) Review reattribution ideas that have been helpful
VIDEO DEMONSTRATION OF UNDERSTANDING VOICES
COGNITIVE RESTRUCTURING Teach clients the connection between thoughts and feelings Explain that the thoughts people have are often automatic and are often related to past experiences (e.g., traumatic) and self-perceptions Facilitate the examination of evidence supporting thoughts and beliefs underlying strong negative feelings
COGNITIVE RESTRUCTURING (Contd) Help clients challenge and modify upsetting thoughts and beliefs that are not supported by evidence by: Socratic questioning Exploring alternative beliefs Behavioral experiments Teaching how to recognize distorted thinking styles
CR TARGETS IN CBTp Accuracy of distressing belief Utility of holding onto belief Beliefs about the power and controllability of voices/persecutors Negative core beliefs about self, other s perceptions of self, future Self-stigmatized beliefs related to illness Beliefs about medications and treatment
SOCRATIC QUESTIONING OVERVIEW -Build rapport, engagement -Can be an MI technique -Explore how person understand an event, voice, thought, etc. -Explore possible consequences of staying with particular maladaptive thoughts or behaviors -Help clients to question own inaccurate or distressing assumptions, beliefs and behaviors -Help clients arrive at a new view of the situation that is more in line with evidence
SOCRATIC QUESTIONING STYLE Colombo-like style: freely admit confusion when trying to understand something, ask for client s help in resolving confusion Ask, don t tell Probe questions Gentle, non-judgmental curious style don t interrogate! Foster client s curiosity too
HOW TO: SOCRATIC QUESTIONING Explore meaning client attaches to a specific event, voice, thought What does it say about you that you are being watched by the government? If this were not the case, what would that say about you as a person? Explore possible consequences of staying with particular maladaptive thoughts or behaviors So, what happens if you continue to yell at your voices in public? You spend a lot of time thinking about the idea that you need to develop superpowers to read others minds in order to be happy. I wonder if that gets in the way of you pursuing other meaningful things in life?
HOW TO: SOCRATIC QUESTIONING (Cont d) What do you make of the fact that your brother says he can t hear what you hear? I wonder if it might be important for us to talk more about your belief that you are adopted, since it is causing so much distress? I m curious: what sorts of things got you thinking that your co-workers were poisoning your lunch? You ve mentioned that you are being terrorized by people on the street. What s your sense of why that might be? Help me understand a bit more about how that brain implant device works.
EXPLORING DYSFUNCTIONAL BELIEFS ABOUT VOICES Common Belief Omnipotence Examples My voice is all powerful My voice is in charge of everything I do My voice is all-knowing Whatever they say must be true The voices want to harm me, punish me, or kill me If I don t listen to the voices, they will punish me I cannot ignore my voices Omniscience Malevolence Controllability
EXPLORING BELIEFS ABOUT VOICES: HELPFUL PROBE QUESTIONS Control How much control do you have over the voices? Are there some things the voices told you to do where you drew the line and refused? Power Who is more powerful, you or the voices? Do the voices make empty threats?
EXPLORING BELIEFS ABOUT VOICES: HELPFUL PROBE QUESTIONS (Cont d) Trustworthiness Do the voices ever provide contradictory information? Have they ever lied? Can they always be trusted? Usefulness of Listening/Complying What important information has the voices given you over the years? Do the voices ever give you misinformation or lead you on a wild-goose chase?
EXPLORING BELIEFS ABOUT VOICES: HELPFUL PROBE QUESTIONS (Cont d) Malevolence Have the voices ever been helpful or kind? Is there anything you might miss about the voices if they were gone?
OVERVIEW: EXPLORING ALTERNATIVE BELIEFS Teach cognitive flexibility as a skill Pre-cursor to CR Begin with coaching around generating alternative beliefs for everyday scenarios Then progress to scenarios that are tailored to the individual s delusional or paranoid beliefs
EXPLORING ALTERNATIVE BELIEFS (Contd) Behavioral scaffolding Start with identified alternative responses to situation, move toward coaching of additional responses, then to independence with the exercise items Helpful probe questions: What s another possible explanation for why this may have happened? What factors related to____(the situation/the way the world works/the person involved in the scenario/you) may have caused or contributed to this happening?
BASED ON THE COGNITIVE MODEL Someone calls you on the phone and doesn t leave a message It s the mafia Anxious, scared It was a wrong number Calm It was a telemarketer Slightly Annoyed
