Cognitive Behavior Therapy (CBT) for Psychosis


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Presented by: Dawn I. Velligan, Ph.D.
Professor, Department of Psychiatry
Director, Division of Schizophrenia and Related Disorders
Meredith L. Draper, Ph.D.
Assistant Professor, Department of Psychiatry
University of Texas Health Science Center, San Antonio

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  • SMI – Bipolar disorder, schizophrenia or MDD-treatment refractory Likelihood of running into someone with SMI as a law enforcement agent/crisis team - high
  • N
  • A review of schizophrenia
  • We will have participants split up into groups of 3 – do the try to speak with someone what a third person is talking in their ear Process what this was like….
  • Ask – given their experiences of voice hearing in a safe environment…what must that be like?
  • Normalizing begins with the clinician or intervening person’s opinions about these experiences. If you are frightened or judgmental of someone’s experience – particularly in a crisis – this may escalate the situation
  • Here is a revised pie chart accounting for more of the contributory factors that led to the company losing money. The pie chart or ratings do not have to add to 360 degrees or 100%. The person may see that there is only 1% left after all the others have been allocated a role. The goal is not to teach them maths. At the end of this process the idea is to demonstrate that there are usually more than one factor involved. The numbers and percentages above are not real. So at the end the question may be “ now that we have reviewed all of the factors that contributed to the company losing money it seems that only about a quarter was down to you. What do you make of this?” Thinking about it now, how much do you think you were to blame? How much do you believe it now? How does this make you feel? Hopefully the person will see that there were a number of factors contributing and that when these are in mind the person does not feel so bad.
  • Cognitive Behavior Therapy (CBT) for Psychosis

    1. 1. Cognitive Behavior Therapy (CBT) for Psychosis Basic Tenets and Skills for Interacting with Individuals Experiencing Psychotic Symptoms Dawn I. Velligan, Ph.D. Professor, Department of Psychiatry Director, Division of Schizophrenia and Related Disorders Meredith L. Draper, Ph.D. Assistant Professor, Department of Psychiatry University of Texas Health Science Center, San Antonio Supported by grant # R01 MH082793
    2. 2. Cognitive Behavior Therapy for Psychosis (CBTp) <ul><li>Serious mental illness and the criminal justice system </li></ul><ul><li>Understanding psychosis </li></ul><ul><li>Basic CBT techniques </li></ul>
    3. 3. Serious mental illness and the criminal justice system
    4. 4. Serious Mental Illness (SMI) and Criminal Justice Involvement <ul><li>Research indicates that 15-24% of U.S. inmates have severe mental illness (Baillargeon, et. al., 2009) </li></ul><ul><li>Rates tend to be higher for women than men </li></ul><ul><li>Individuals with SMI experience 3 to 6 times the rate of incarceration than the general population (U.S. Dept. of Justice, 2009). </li></ul>
    5. 5. Judicial Involvement of Individuals with Psychosis <ul><li>According to the Department of Justice, 15%-24% of all prison and jail inmates respectively report psychotic symptoms (Lamberti, 2007) </li></ul>
    6. 6. Recidivism of Individuals Diagnosed with an SMI <ul><li>A recent retrospective study of Texas Department of Criminal Justice statistics indicated: </li></ul><ul><ul><li>Inmates diagnosed with bipolar disorder and psychotic disorders had a substantially higher risk of recidivism than inmates without SMI over a six year period (Baillargeon, et. al., 2009). </li></ul></ul>
    7. 7. When incarcerated….. <ul><li>Studies show that individuals with SMI frequently do not receive adequate psychiatric treatment (Lamberti, 2007) </li></ul><ul><ul><li>They are not identified </li></ul></ul><ul><ul><li>Receive only medication treatment while in custody </li></ul></ul><ul><ul><li>May not follow up with or be connected to ongoing services when released </li></ul></ul>
    8. 8. A Review of schizophrenia and psychosis
    9. 9. Schizophrenia: Signs and symptoms related to outcome <ul><li>Negative Symptoms </li></ul><ul><li>Affective Blunting </li></ul><ul><li>Poverty of speech </li></ul><ul><li>Amotivation </li></ul><ul><li>Decreased activity </li></ul><ul><li>Social withdrawal </li></ul><ul><li>Cognitive Deficits </li></ul><ul><li>Attention </li></ul><ul><li>Memory </li></ul><ul><li>Executive functions </li></ul><ul><li>Comorbid Conditions </li></ul><ul><li>Mood </li></ul><ul><li>Substance abuse </li></ul><ul><li>Anxiety </li></ul><ul><li>Community Functioning </li></ul><ul><li>Work/School </li></ul><ul><li>Interpersonal relationships </li></ul><ul><li>Self-care/ADLs </li></ul><ul><li>Positive Symptoms </li></ul><ul><li>Delusions </li></ul><ul><li>Hallucinations </li></ul><ul><li>Disorganized speech/behavior </li></ul>
    10. 10. Living with Schizophrenia <ul><li>Cognitive deficits lead to problems with organization and planning…. </li></ul>
    11. 11. Symptoms can cause… <ul><li>Isolation </li></ul><ul><li>Family/social conflict </li></ul>
    12. 12. Partial Compliance and Hospitalization Weiden PJ et al. Psychiatr Serv. 2004;55:886-891. Longest medication gap (days) N=327 N=1710 N=1166 N=1122 6% 12% 16% 22% 0 1-10 11-30 >30 Patients hospitalized (%) Studies with better methodology demonstrate that patients take About 50% of prescribed medication 0 5 10 15 20 25
    13. 13. How might you spot someone with SMI? What does psychosis look like? <ul><li>People with psychosis </li></ul><ul><li>People without psychosis </li></ul>
    14. 14. Dichotomy or Continuum? <ul><li>We all have experiences and/or beliefs not understood by others </li></ul><ul><ul><li>The extent to which an individual is convinced of the belief may differ </li></ul></ul><ul><ul><li>The effect that the belief has on daily functioning may differ </li></ul></ul><ul><li>Understanding this continuum is essential for being able to apply CBT techniques </li></ul>
    15. 15. Continuum of Experience I’d like to have more money… What would it be like if I won the lottery….I’d definitely buy a boat…a blue ski boat with a wakeboard…. I just woke up and for a moment I really thought I’d won the Powerball - $18M! I am really a millionaire, but a group of Satanists is trying to take all my money… Normal thoughts Imagination Dreams Delusions and hallucinations
    16. 16. Many people have beliefs others do not profess or understand About 75% Americans profess at least one paranormal belief, according to a 2005 Gallup survey. ESP 41% Houses can be haunted 37% Ghosts/Spirits 32% Telepathy 31% Clairvoyance 26% Astrology 25% Witches 21%
    17. 17. Politics Today <ul><li>Individuals on the right cannot understand the beliefs of those on the left </li></ul><ul><li>Individuals on the left cannot understand the beliefs of those on the right </li></ul><ul><li>Each side has individuals with full conviction who believe they are 100% correct and the other side is 100% wrong </li></ul><ul><li>Beliefs are strongly defended and each bit of evidence is weighed differently by different sides </li></ul>
    18. 19. Zoe Wanamaker (actress) Beethoven (composer) Sir Anthony Hopkins (actor) Brian Wilson (Beach Boys) Joan of Arc (saint and heroine of France) Sigmund Freud (psychoanalyst) John Frusciante (guitarist, Red Hot Chili Peppers) Normalizing: Famous Voice Hearers Slide courtesy of Sara Tai, Clin.Psy.D., University of Manchester
    19. 20. Winston Churchill, Prime Minister of Britain during the second world war and famous speech maker, suffered from depression, and also heard voices. Winston Churchill is credited as being the greatest of all Britain’s war leaders. During World War II, Churchill's &quot;voices&quot; would tell him to &quot;sit here&quot; or &quot;sit there?&quot; (Funk & Wagnalls Encyclopedia, 1990, &quot;Hallucinations.&quot;) Normalizing: Famous Voice Hearer: Winston Churchill
    20. 21. Developing an Understanding of the Voice Hearing Experience <ul><li>GROUP EXERSIZE </li></ul>
    21. 22. What if you heard voices and were in crisis? <ul><li>We know that the stress can exacerbate psychotic symptoms. </li></ul><ul><ul><li>Voices </li></ul></ul><ul><ul><li>Delusions </li></ul></ul><ul><ul><li>Disorganized Thinking </li></ul></ul>
    22. 23. Circumstances leading to hallucinations in the general population <ul><li>Waking up or falling asleep </li></ul><ul><li>Sensory deprivation </li></ul><ul><li>Substance use </li></ul><ul><li>Sleep deprivation </li></ul><ul><li>Bereavement </li></ul>
    23. 24. What leads to a diagnosis? <ul><li>Having a hallucination does not lead to a diagnosis </li></ul><ul><li>The frequency of occurrence, the meaning of these experiences to the individual and the extent to which they interfere with functioning may determine whether or not someone who experiences hallucinations has a diagnosis </li></ul>
    24. 25. A Review of Psychosis <ul><ul><li>Many individuals treated with antipsychotic medications continue to experience delusions and/or hallucinations. </li></ul></ul><ul><ul><li>These persisting positive symptoms can be extremely distressing and negatively impact daily functioning. </li></ul></ul>Sensky et al., 2000; Kane & Marder, 1993; Pantelis & Barnes, 1996; Wiersma et al., 1998; O’Connor & Herman, 1993; Cather et al., 2004
    25. 26. SMI and Trauma <ul><li>Individuals with SMI have a high prevalence of trauma histories and post traumatic stress disorder (PTSD) (Lommen & Restifo, 2009) </li></ul><ul><ul><li>30-40% of patients experiencing psychosis meet criteria for PTSD (Mueser, et. al., 2002) </li></ul></ul><ul><ul><li>13-29% of individuals with schizophrenia are diagnosed with comorbid PTSD </li></ul></ul><ul><ul><li>Individuals with SMI are more likely than the general population to be victims of crime (Levin, 2005) </li></ul></ul>
    26. 27. Overview of Cognitive Behavioral Therapy for Psychosis
    27. 28. Cognitive Behavioral Therapy for Psychosis <ul><li>A brief description of CBT for psychosis </li></ul><ul><li>A model to understand the creation, maintenance and exacerbation of psychotic symptoms </li></ul><ul><li>Efficacy of CBT </li></ul><ul><li>Techniques to use with individuals experiencing psychosis in crisis situations </li></ul>
    28. 29. Cognitive Behavior Therapy <ul><li>Pioneered in the U.S. by Aaron Beck </li></ul><ul><li>Beck described an individual with paranoid delusions who was treated by exploring the events preceding the development of the delusions and examining evidence supporting or refuting his belief that individuals were members of a government agency and were tormenting him. Over time the patient was able to cross individuals off his list of persecutors until there were none remaining. </li></ul>(Beck, 1952)
    29. 30. Theoretical Framework of CBT <ul><li>Stress-Vulnerability model </li></ul><ul><li>Reasoning and appraisal biases </li></ul>
    30. 31. Stress-Vulnerability Model of Psychosis
    31. 32. Stress-Vulnerability Model Money Problems Relationship Break-up
    32. 33. Stress-Vulnerability Model Money Problems Relationship Break-up Assault Substance Use Fight with boss Speeding Ticket This is often the state during an encounter with law enforcement
    33. 34. Stress-Vulnerability Model Money Problems Relationship Break-up Assault Substance Use Fight with boss Speeding Ticket Medication Family Support Someone to listen Regular Sleep
    34. 35. Emotional Processes contributing to the development and maintenance of positive symptoms <ul><li>We know that psychoses are partly genetically determined: Stress-Vulnerability Hypothesis </li></ul><ul><li>Under stress, individuals who have an inherited genetic vulnerability will go on to develop psychotic symptoms. </li></ul><ul><li>The content of delusions and hallucinations can vary greatly by individual and is partly determined by their unique emotional experiences. </li></ul><ul><li>The more you understand about the individual the more you can help </li></ul>
    35. 36. Symptoms come from Information Processing Deficits and Reasoning Biases <ul><li>Similar to what occurs in depression, a person can develop world views that will predispose them to paranoia or other types of delusional thinking should they become psychotic. </li></ul><ul><li>Information is then interpreted in light of these pre-existing models. Confirmatory evidence is weighted more heavily. </li></ul>
    36. 37. 85:15 ratio The Beady Task
    37. 38. <ul><li>Pull out a series of beads one at a time using only 1 jar </li></ul><ul><li>Ask when the person is convinced about which jar the beads came from </li></ul>
    38. 39. Beads seen before deciding! (Dudley et al., 1997a)
    39. 40. Cognitive Behavior Therapy <ul><li>Focus on those with continuing psychotic symptoms despite optimal (or sometimes not) medication treatment. </li></ul><ul><li>Aims to reduce the intensity of delusions and hallucinations and related distress. </li></ul><ul><li>Interventions focus on rational exploration of psychosis, challenging beliefs, reality testing, develop coping strategies. </li></ul>
    40. 41. Efficacy of CBT <ul><li>Meta-analytic studies support efficacy of CBT, especially in treatment of positive symptoms in chronic patients. </li></ul><ul><ul><li>Gould et al (2001) </li></ul></ul><ul><ul><li>Rector & Beck (2001) </li></ul></ul><ul><ul><li>Pilling et al (2002) </li></ul></ul><ul><ul><li>Tarrier & Wykes (2004) </li></ul></ul><ul><ul><li>Zimmerman et al (2005) </li></ul></ul><ul><ul><li>Wykes, Steele, Everitt & Tarrier (2008) </li></ul></ul>
    41. 42. Status of CBTp in the treatment of psychosis (Tarrier & Wykes, 2004) <ul><li>Identified 20 trials that have a control group, the majority randomised, that have evaluated some ‘brand’ of CBT to treat schizophrenic patients. </li></ul><ul><li>All are one-to-one therapy. </li></ul><ul><li>All assess positive psychotic symptoms in some way. </li></ul><ul><li>739 patients treated with CBTp with a mean of 37 treated in each study (sd=48, range 7-225). </li></ul><ul><li>mainly chronic patients (17/20) outpatients (16/20) </li></ul><ul><li>Acutely ill patients (3/20) </li></ul><ul><li>16 in UK, 1 each from Canada, Holland, Italy, & USA </li></ul>
    42. 43. Effect Sizes from CBTp studies (post-treatment CBTp/control) <ul><li>Data available from 19 studies. </li></ul><ul><li>Mean ES =0.37 (sd=0.39, median=0.32, range -0.49 to 0.99). </li></ul><ul><li>74% achieved at least a small ES, </li></ul><ul><li>32% a least a moderate ES, </li></ul><ul><li>16% a large ES </li></ul>
    43. 44. Example studies <ul><li>Kuipers et al. (2006) randomized patients to usual care versus cognitive therapy sessions over 9 months. The CBT group had a greater reduction in psychiatric symptoms and a greater proportion of responders than standard care (50% versus 31%). </li></ul>
    44. 45. Responders to 9 months of CBT versus Standard Care 50 31 0 10 20 30 40 50 60 CBT Standard Care Percent Responding Kuipers et al. (2006)
    45. 46. 35.6 20.5 15.1 36.6 22.9 26.6 10 15 20 25 30 35 40 CBT Active Control Baseline 9 months 18 months Treatment Phase Follow-up Symptoms CBT versus an active comparator treatment Sensky et al., 2002
    46. 47. CBT for Law Enforcement <ul><li>Helps to understand the individual’s perspective, how they think and feel </li></ul><ul><li>An understanding and application of CBT approaches can help to deescalate crisis situations </li></ul>
    47. 48. Techniques Informed by CBT for Psychosis
    48. 49. Techniques <ul><li>Making a connection </li></ul><ul><ul><li>How to engage someone experiencing psychosis </li></ul></ul><ul><li>Normalizing </li></ul><ul><ul><li>Focus reducing stigma </li></ul></ul><ul><li>Formulation </li></ul><ul><ul><li>How to make some sense of psychotic experiences </li></ul></ul><ul><li>Crisis Management </li></ul><ul><ul><li>Deescalating someone who is psychotic </li></ul></ul>
    49. 50. Engagement <ul><li>Awareness of STIGMA: </li></ul><ul><ul><li>People experiencing psychosis often see themselves as completely different from others. They feel alienated and do not believe their experiences can be understood by “normal” people. </li></ul></ul><ul><ul><li>They may believe that having these experiences will keep them from ever having friends and relationships or from attaining other goals they may hope for. </li></ul></ul>
    50. 51. Engagement <ul><li>Oftentimes individuals experiencing psychosis are used to being put off or not heard </li></ul><ul><li>Consumers with long histories of mental illness report never being asked questions like “How did all this start?” </li></ul><ul><li>Awareness of cultural values </li></ul><ul><ul><li>may impact the understanding (positive or negative) of psychotic symptoms </li></ul></ul>
    51. 52. Formulating (Making Sense) Trigger Psychotic Symptom Belief about symptom Consequence Behavior
    52. 53. Formulating (Making Sense) Fight with Mom about medicine Hear a voice Mom is trying to poison me Fear No sleep Threatens to hurt mom, she calls the police
    53. 54. Many patients state that the brain disease model degrades and demoralizes them Your brain is defective!
    54. 55. Automatic thoughts <ul><li>Others will despise me! </li></ul><ul><li>I will be a burden! </li></ul><ul><li>There is utterly nothing good about this! </li></ul><ul><li>There is no hope! </li></ul><ul><li>I will deteriorate and end up on the streets! </li></ul><ul><li>Everyone is trying to hurt me. </li></ul><ul><li>Emotions dread, despair and anger. </li></ul>
    55. 56. Normalizing: the antidote to Stigma. <ul><li>Normalizing is a technique for engaging with the individual </li></ul><ul><li>The goal is to avoid catastrophizing and understand that: </li></ul><ul><ul><li>Virtually everyone faces a significant illness at some point in their life </li></ul></ul><ul><ul><li>Their experiences are more common than they may realize and are a struggle that affects many people in many cultures </li></ul></ul><ul><ul><li>The illness is not anyone’s fault </li></ul></ul><ul><ul><li>A large number of people overcome most symptoms </li></ul></ul>
    56. 57. Normalizing <ul><li>While not everyone with SMI will be famous, understanding that individuals can recover from SMI is a message that people with psychosis often do not hear. </li></ul>
    57. 58. Best normalising explanations of voice hearing <ul><li>Bereavement </li></ul><ul><li>Trauma </li></ul><ul><li>Lack of sleep </li></ul><ul><li>Para-psychological </li></ul><ul><li>Shamanistic </li></ul><ul><li>Brain biology and stress. </li></ul>
    58. 59. Normalizing Exacerbation of Psychotic Symptoms Symptoms e.g. hearing voices Worry e.g. ‘ I’m going crazy’ ‘ I’m in danger’ Feel upset, anxious, depressed etc Symptoms get worse
    59. 60. Client Comments and Normalizing Responses <ul><li>“ I know you’re going to take me to jail because I hear voices”. </li></ul>Everyone has some kind of problem. Just because you hear voices doesn’t mean you will go to jail. Voices are a reaction to stress. Under stressful situations a lot of people can hear voices.
    60. 61. Client comments and Normalizing Responses <ul><li>I will be locked up in a hospital forever. </li></ul>Lots of people have illnesses that need to be managed for a short time in the hospital. You can get to feeling better and then learn to manage your symptoms in the community.
    61. 62. Client comments and Normalizing Responses Did you know that lots of people that don’t have an illness can hear voices. Many people hear voices when they are just falling off to sleep. <ul><li>Only crazy people hear voices. </li></ul>
    62. 63. Help for people with delusions: Basic Socratic questions to diffuse agitation <ul><li>Colombo style questioning </li></ul><ul><li>E.g. What would happen if you woke up with green spots covering your legs? </li></ul><ul><ul><li>How would you feel? </li></ul></ul><ul><ul><li>What might you think? </li></ul></ul><ul><ul><li>What would you do? </li></ul></ul><ul><ul><li>What would you need? </li></ul></ul>
    63. 64. Delusional Conviction: Coughing means there is a conspiracy against me 90% Convinced that a spell has been placed on me 10% Believe there may be another explanation
    64. 65. Pie Charts-Discuss Reasons People Cough—Re-rate original belief in light of alternative information Re rate original belief and emotion in light of alternative information
    65. 66. 911 call from a woman complaining of a home invasion <ul><li>A woman reports has just returned home and her house has been broken into. </li></ul><ul><li>When the police arrive, she is very upset and reports she is certain someone has been in her house because the milk is in the wrong place. </li></ul><ul><li>How would you handle this? </li></ul>
    66. 67. Ride the Bus-Don’t allow safety behavior
    67. 68. Ride the Bus-Don’t allow safety behavior
    68. 69. Ride the Bus-Don’t allow safety behavior
    69. 70. Sometimes delusions can bolster self-esteem <ul><li>In this case it is important to help the individual find a realistic basis for accomplishment and self esteem </li></ul>Case Example: John was arrested by the police for standing in the middle of the highway and trying to get into other people’s cars. He believed he was the king of the Belgium and was expecting his ride home. Belief Protects: “I am just a mental patient.”
    70. 71. Choosing your words <ul><li>Individuals experiencing psychosis are used to having to defend their ideas and to being patronized. </li></ul><ul><li>Do not directly confront their beliefs ideas. </li></ul><ul><li>It is equally important not to collude with them. </li></ul>
    71. 72. Choosing your words <ul><li>Phrase questions in a way that does not suggest collusion with the delusion. For example, it is not helpful to say, “What is making the CIA follow you.” It is better to say, “What do you think would make the CIA follow you.” </li></ul><ul><li>The first phrasing implies that the CIA is actually following the patient, where as the second suggests that this a thought the patient has. </li></ul><ul><li>A colluding response may also be “It is possible the CIA is doing that” A more neutral response is pointing out that the patient first thought they were being followed 2 years ago. </li></ul>
    72. 73. Do not seize upon doubt expressed by the patient immediately <ul><li>For example, if the patient states, “It could be my imagination,” the therapist should not say, “That is very likely.” The patient here may be testing the objectivity of the therapist. </li></ul><ul><li>A more neutral statement such as “That is one possibility, but you said you had many experiences that you thought proved your idea. Let’s talk about some of those.” </li></ul>
    73. 74. Conclusions <ul><li>Simple things to do to diffuse situations </li></ul><ul><li>Try to make sense of the person’s experience </li></ul><ul><li>Normalize </li></ul>