Choices

• empower service users and carers with informed choices about options for reducing distress and improving quality of life

• “the literature makes it abundantly clear that service users want to be offered more than just medication” (Warner, Mariathasan, Lawton-Smith, & Samele, 2006)

• Choosing not to take antipsychotics may be a rational decision in relation to cost-benefit profile

Our Approach

• To increase awareness in primary care services, secondary care services, voluntary sector, further education and the community

• Increase referrals through– Training for potential referrers– Rapid response– Flexible approach to clients– Positive, user friendly service

• Use of cognitive therapy

Can a cognitive model be applied to distressing psychotic

experiences?

On the next slide carry out the following instructions

Stare at the blue dots while you count slowly to 30.

Then close your eyes and tilt your head back. A circle of light will slowly appear. Keep looking at it.

What do you see?

Hearing voices exercise

What is schizophrenia?

• two or more of: delusions, hallucinations, disorganised speech, grossly disorganised/catatonic behaviour, negative symptoms (flat affect, poverty of speech, avolition)

• social/occupational dysfunction - at least one of work/interpersonal relationships/self-care

• at least 6 months (with at least 1 month of symptoms above)

• exclusions for mood disorders/schizoaffective disorder/ organic damage/ substance induced Sx

Principles of Cognitive Therapy for Anxiety Disorders

· A cognitive model is required from which to empirically derive effective treatments

• You are not mad – you are normal• Either it is real or you believe it to be real• How you appraise events affects how you feel• Test it out – drop your safety-seeking behaviours• It’s not what you think, it’s how you think

Morrison (1998)

Triggers

Auditory Hallucinations

Mood & Physiology Safety Behaviours

Misinterpretation of Hallucinatory Experience

Cultural acceptability?

• if someone misinterprets their racing thoughts or palpitations as a sign of alien control or persecution via telekinesis, they will be classified as delusional, whereas misinterpretation of the same sensations as a sign of impending madness or a heart attack would be regarded as indicative of panic disorder

• a benign lump in one's skin may be misinterpreted as a sign of cancer by a hypochondriacal patient, but the misinterpretation of the same stimuli as being a transmitter or homing device installed by the secret police would be more likely to result in a patient being regarded as psychotic

A Cognitive Model of Psychotic Symptoms

intrusion from low level processing units

(cognitive, body state, emotional or external information)

interpretation of intrusion (culturally unacceptable)

faulty self & social knowledge (procedural and declarative beliefs)

experience cognitive and behavioural responses mood & physiology (including safety behaviours, selective attention and thought control strategies)

Morrison, A. P. (2001) The interpretation of intrusions in psychosis: An integrative cognitive approach to hallucinations and delusions. Behavioural and Cognitive Psychotherapy, 29, 257-276.

What happenedEvent /intrusion

How I make sense of it

Beliefs about yourselfand others

Life experiencesWhat do you do when thishappens

How does it make you feel

Experiences that worry meHear whispering and laughingSee bodiesSee people staring

What I make of itThey might be ghostsI must be going madThey might harm me

What I make of the self / worldI should be in total controlI am badNeed to be alert for dangerOther people cannot be trusted

Early experiencesBaby brother died, mum blamed meSexually abused aged 14Dad horrible to me

What I doTry to stay in control of thoughts Hide from ghostsLook out for things happening to me

How I feelscaredagitatedangrysad

Video

• EFTB formulation for voices

What is changed during CT for people with psychosis / PEs?

• Appraisals of, and responses to, psychotic experiences

• Whatever is put on the problem list!• Conviction in, frequency of, preoccupation

with and distress in response to PEs• Can change occurrence of PEs. However, the

aim is to change relationship to PEs, making them less significant / distressing– e.g. voices may be reattributed as intrusive

memories or thoughts (and disappear), but this is a side-effect of developing a less distressing explanation

What is changed during CT for people with psychosis / PEs?

• Implication of model is that trying to eliminate PEs in people with a diagnosis of schizophrenia would be like trying to eliminate body sensations in patients with panic disorder or intrusive thoughts in patients with OCD

• Also, normal experiences with understandable consequences due to misinterpretation RATHER THAN AN ILLNESS

I don’t think it’s [CBT] used to eliminate them altogether its knowing why you get the voices erm…how to deal with them basically” (7)

Intervention - Process

• develop therapeutic relationship• assessment• establish shared problem list• translate into ‘smart’ goals• formulation• interventions derived from formulation• relapse prevention

Intervention

• Formulation driven

• Based on cognitive model

• Follow principles of CT

• Follow session structure of CT

Intervention – default assumptions

• Can develop a therapeutic relationship relatively quickly

• The assessment process, establishing shared problem list, translating into ‘smart’ goals and developing formulation are inherently engaging for most people – collaboration and cards on table

• We can develop these quickly (e.g. by session 2-6) • Formulation is useful for: demonstrating/promoting

understanding, validating experiences and selecting change strategies, but it is not an intervention strategy on it’s own

• Change strategies such as behavioural experiments and verbal reattribution methods are what produce changes

• Structure and homework are necessary for making process explicit and facilitating learning

Engagement

• Interventions should be informed by client feedback

• Normalising of psychotic symptoms should be used to reduce stigma and improve engagement

• CBT should require consistent collaboration throughout the sessions

• The rationale of CBT should be explained and demonstrated to the client

• CBT should aim to reduce distress and improve quality of life

• CBT should aim to elicit hope in recovery• Session structure and content should be decided jointly

between client and therapist• Agreed short and long-term goals should underpin the

intervention• Guided discovery should be used to help the client gain

understanding• Goals should be SMART (Specific, Measurable,

Achievable, Realistic and Time limited)• Over the course of therapy a client should work towards

becoming their own therapist

• Socratic questioning, diaries and monitoring procedures should help the client reflect upon and explore new meanings about their thinking, behaviour and context

Structure and principles

Formulation

• A good collaborative relationship must be formed to help develop a comprehensive formulation

• A formulation should be developed and used to outline a treatment plan

• A cognitive-behavioural maintenance cycle should be devised and used to set targets for intervention

Assessment and model

• CBT should be idiosyncratic to the individual client

• CBT should examine the role that behaviours have in triggering and maintaining the clients difficulties

• CBT should help a client to identify and elicit those thoughts, images and beliefs which are fundamental to their distress (i.e. the key cognitions)

• CBT ought to elicit and examine behavioural patterns such as “safety seeking behaviours” in relation to the relevant emotions associated with them

Homework

• ‘Homework’ should be a ‘standing’ item on the agenda

• Homework assignments ought to act as a bridge between therapy and the real world

Change strategies

• Logging pros and cons should be used to explore voices

• With CBT the client should be supported to explore alternative explanations of experiences that may be more adaptive and less distressing

• Beliefs in omniscience and omnipotence of command hallucinations should be explored and debated

• Experiments should be devised to test beliefs by modifying safety behaviours

Therapist assumptions

• Therapists should believe that many people experience psychotic-like symptoms without feeling distressed by them

• Therapists ought to believe that delusions can be quite understandable

• Therapists should believe that it is not the hallucination or the delusion per se that is clinically relevant but the amount of distress or disability associated with it

• Therapists ought to view most symptoms of psychosis as quite common in the normal population

Therapists should not assume

• Therapists should NOT believe that clients with psychosis are very different to clients with other mental health difficulties

• Therapists should NOT believe that there is a clear boundary between being mentally unwell and mentally healthy

Differences• Check if involved in symptoms• Make allowances for memory &

attention• Written copies of hw tasks, rationale etc• Session summary sheets• Shorter, more frequent sessions• Importance of tape as homework• Importance of structure & instilling process• Shorter agenda• Importance of therapeutic relationship &

engagement

• Pacing

Assessment

• Elicit information to flesh out formulation

• Standard cognitive behavioural assessment

• Experiences – interpretations – responses

• Use blank conceptualisation as guide