Our Conversations lecture 'Hope, Humanity and Empowerment: Strengths-focused Cognitive Behavioural Therapy for Psychosis (& Schizophrenia)' was presented by staff members of the Integrated Forensic, Recovery and Schizophrenia programs at The Royal. Psychosis can be associated with a variety of mental health problems, including schizophrenia, severe depression, bipolar disorder, anxiety, and post-traumatic stress disorders. While traditional treatments for psychosis have emphasized medication-based strategies, research now suggests that individuals affected by psychosis can greatly benefit from talk therapies such as cognitive behavioural therapy for psychosis (CBTP). Learn more: www.theroyal.ca

1. Hope, Humanity and
Empowerment:
Strengths-focused Cognitive Behavioural Therapy
for Psychosis (& Schizophrenia)

2. Agenda
• Introductions and welcome (bilingual)
• CBTP Origins and Strategies
• Why a strengths, humanistic, meaning making and recovery
oriented approach is so important (NAMI poster other slides)
• Video
• Goals and meaning
• The whole person-complementing meds
• Stigma
• Peer Support: hope and empowerment
• WRAP and recovery
• Resources - family sessions
• Q & A

3. Brought to you by….
The Integrated Forensics, Recovery and
Schizophrenia Programs of The Royal
With thanks to support from:
•University of Ottawa Medical Research Fund
•The Institute of Mental Health Research

4. Presenters
• Tiffany Clough: Peer
• Diane Hoffman-Lacombe: Psychologist, Forensics
• Raphaela Fleisher: Social Worker, Forensics
• Tom Fogl: Psychiatrist, Schizophrenia
• Anik Gosselin: Psychologist, Forensics, Brockville MHC
• Sandra Jacquens: Social Worker, Schizophrenia
• Dylan Myllymaki: Social Worker, Schizophrenia
• Carlo Verdicchio: Peer Support Worker, Recovery
• Nicola Wright: Psychologist, Schizophrenia

5. Introduction to CBT for Psychosis:
Origins & Strategies
Presented by:
Diane Hoffman-Lacombe, M.Ps., C.Psych
Raphaela Fleisher, MSW, RSW

6. What is CBTp?What is psychosis?
THOUGHTS
EMOTIONS BEHAVIOURS
CBT for Psychosis

7. What is Psychosis?
• Psychotic experiences (eg. hallucinations, delusions can have
difficulties with thoughts, behaviors and emotions)
• Conceptualization of psychosis on a continuum
• Delusions (unusual beliefs) that are not based on facts &
hallucinations (unusual perceptions, such as voices) are part
of human experience
• Psychosis is a core feature of a number of different
conditions (eg. schizophrenia, schizoaffective disorder, brief
psychotic disorder, delusional disorder, etc.)
• Can be a feature of bipolar, depression, post traumatic stress
disorder, & other conditions)
• Context is important: cultural norms, practices & beliefs

8. What is CBT for Psychosis (CBTP)
• CBT = cognitive behavior therapy
• Behavioral and emotional responses linked to cognitions – thoughts
(appraisal of events; interpretation; perspective)
• CBT is a form of psychotherapy developed by Dr. Aaron Beck (1960s)
• Empirically validated for numerous conditions including
psychosis/schizophrenia (see National Institute of Clinical Excellence
Guidelines)
• CBT for Psychosis (1990s-early 2000s)
• Emphasize strong therapeutic alliance; psychoeducation & normalization;
skills & strategies to address stress and reduce distress, symptoms such as
delusions, hallucinations & lack of motivation are addressed as barriers to
meaningful goals
• Focus on STRENGTHS, VALUES, GOALS & RECOVERY

9. Objectives of CBTP
• Enhance recovery / quality of life
• Normalize emotions and experiences; give another way to
look at experience
• Normalize through psychoeducation
• Finding meaning (making sense of unusual experiences;
symptoms like hallucinations & delusions
• Decrease distress through…
• Coping tools and techniques
• Skill development
• Strategies to cope with symptoms that are barriers to
MEANINGFUL GOALS, QUALITY OF LIFE & RECOVERY

10. CBTP Group: Topics for 17 Sessions
• Intro to CBT (goals & pleasant activities)
• CBT: what it can do for you (the CBT triangle and the ABC model)
• Getting active & negative symptoms
• Thoughts that get in the way of getting active
• Thinking styles: noticing my thoughts & checking them out
• Checking out troubling automatic thoughts
• Voice hearing & other hallucinations
• CBT Strategies for troubling thoughts & hallucinations
• CBT Strategies: advantages & disadvantages and finding meaning
• CBT Strategies: behavioral experiments
• CBT Strategies for paranoid beliefs
• CBT Strategies for unusual ideas & beliefs
• Shifting Core Beliefs: Feeling Good About Yourself
• Wellness Plan & CBT after the group
• Booster Session / Practice group

11. Toolkit Sample: Coping Strategies
• CBT triangle, ABC, 3C’s, 4C’s
• Evidence for and Against, Decentering, Metathinking
• Thinking styles
• Coping cards-coping affirmations
• Set meaningful goals
• Develop a personal action plan
• Take care of physical health –exercise, sleep, healthy diet, etc,..
• Take medications consistently
• Cool hot thoughts -shift unhelpful thoughts
• Notice & change “shoulds”, “musts” and “oughts”
• Take the other person’s point of view
• Focus on strengths, accomplishments, progress
• Immerse in enjoyable activities
• Develop positive emotions
• Focus on the now instead of worries about the past or future
• Practice mindfulness (1-2 minutes) & relaxation
• Be kind to yourself-self compassion & self-care
• Practice gratitude daily
• Keep a positive log

12. The 3Cs and 4Cs - catch it, check it,
change it (with compassion)
Catch It
(notice it)
Check It Change It
(shift)
Compassion
Everyone
is looking
at me
when I’m
in a mall.
Is it true
that
everyone
is looking
at me?
Not
everyone
is looking
at me.
Take a deep
a breath and
be kind to
myself.

13. Forensic Considerations
• Therapeutic Alliance / Relationship
• Team Communication
• Risk Management
– risk assessment (HARM)
– individual care plan

14. Why a strengths-focused, empowering,
meaning making and recovery oriented
approach is so important
Nicola Wright, Ph.D., Psychologist, Schizophrenia Program, The Royal

15. Positive Psychology; Strengths-
Focus
• Focusing on what’s STRONG not what’s
wrong
• Optimal healthy human functioning
• Strengths, qualities, skills, resources:
promoting health
• Humanistic: actualize potential-empower
• Values, Goals, Dreams
• Achieve meaningful lives
• Coping strategies/skills
• Meaning making –making sense of no(n)-sense

16. Positive Psychology; Strengths-
Focus
• Positive Emotions
• 3:1 ratio
• Negativity bias: threat & mistakes
• Neurons that fire together wire together
• Positive Memories
• Imagery
• Gratitude Exercises
• Positive Log

17. Recovery-Oriented
• Recovery= A meaningful life
– How do we define success?

18. Empowerment-Resilience
• Empowerment:
– CBTP=shift thoughts & beliefs about self, others & the
future
– Enhance self-image
– Voices-Social Rank Theory –power & control
– Stigma
– Motivates to move in valued directions to achieve
meaningful goal
• How: Skills, Knowledge, Understanding
– Meta-thinking: Thinking about your thinking
– Jumping to conclusions, worry, rumination, self-critical,
avoidance, anxious or fearful thinking
I used to think the brain was the most wonderful
organ in my body. Then I realized who was telling me
this.
(Emo Philips)

19. Empowerment-Resilience
• How:
– Emotional regulation & resilience
– Stress & distress –heightened-skills
– You name it you tame it
– What you resist persists-not avoiding
• Eg., shifting relationship with voices

20. The ABC Model
Activating Event Beliefs or
thoughts
Consequences
(Feelings & Actions)
Event or Situation Thoughts 1) Feelings
2) Behaviors
Troubling
thought example
Voice says: “You are a
loser”
I can’t do this
I will fail
1) Sad
2) Stay at home
Balanced-helpful
thought example
Voice says: “You are a
loser”
Maybe the voice is
wrong-I don`t have to
believe the voice
The voice is like a day
time dream (or my
mind playing tricks on
itself)-I can do this
1) Confident
2) Go out

21. Empowerment-Resilience
• Resilience: 3Cs
– Commitment –to valued goals & feeling deeply involved
– Control-have a sense can influence own life
– Challenge- able to turn adversity into a challenge or
opportunity for growth –illness as evolution
• Resilience :
– Face facts-Acceptance
– Choose Life-Live for Future
– Reach Out- to peers, supports
– Get Moving-individual action plan
– Give Back- gratitude & generosity

22. Empowerment-Resilience
• Educate- empowers, normalize, develop
understanding –not alone
• Advocate- addresses stigma, creates resources,
sense of purpose
• Narrate-develop new empowering narrative re.
self & life
• Create- valued future
• Metaphor or Image:
• Mountains
• Canoeing through rough waters to sunny beach

24. HOPE
COURAGE
RESILENCE

25. Values
• Value consistent living
• Move in valued directions
• Motivation-always there
• Courage
• Strength
• Inspirational
• Resilience
• Perseverance
• Overcoming Hardship
• Determination

26. Beauty & Hope
• Compassion, connection, making a difference,
going to the sacred painful places: co-traveller
(mountain image)-our common human content
• School
• Peer Support Worker
• Start own Business
• Poet
• Artist
• Married
• Kids

27. Video
TED Talk: Eleanor Longden

28. Goals and Meaning
By Dylan Myllymaki, MSW, RSW
Social Worker
The Royal

29. Fostering Meaningful Activities,
Purpose, and Action
• Goal planning in group and individual therapy
• Integrate techniques from various therapies:
– CBT (behavioural activation, SMART goal setting, problem
solving, exposure, etc.)
– Acceptance and Commitment therapy (identify core
values, acceptance of uncomfortable thoughts/feelings,
focus on present moment, decrease avoidance,
committed action to valued goals)
– Strengths based & recovery focused (identify strengths,
develop hope, self-determination and personal
responsibility, meaning making, create unique path to
recovery)

30. Typical Goals & Core Values
Typical goals of clients:
1.Romantic and family relationships
2.Work, employment, volunteering
3.Social relationships/peers
Examples of core values:
– Helping others, self-acceptance, generosity, stability,
creativity, etc.

31. Focus on Meaning Creation
• Main focus is on individual values, strengths, and growth; rather than symptoms
and deficits.
• Therapeutic relationship is key. Give up control, let the client take lead on goals.
Be flexible, open-minded, and encouraging (mirror back what you would like to
see with clients).
• Experimental attitude – try out new experiences tied to values as methods to
gather new information about self, others, and the reality of goals.
• Positive emotions and new experiences can create new meaning. Emotions act
as a primary motivator for action.
• Symptoms are addressed as barriers to meaningful activities.
• Values = compass for action (principles that person stands for, they are not
goals).
• No goals, no problem....focus on what is important and meaningful to that
person. Explore and experiment.
• Goals flow naturally out of strengths, values, and interests (past and present).

32. Barriers to Valued Goals
• Ambivalence and resistance – use motivational interviewing
techniques
• Excessive goals – simplifying action plan, self-compassion if goal not
attained, start with smallest first step (e.g. Thinking about goal)
• Remoteness from values – goal is not in line with present values,
goal introjected by others
• Avoidance of discomfort – focus on accepting some discomfort
(within window of tolerance), change is not easy
• Lack of dreams, wishes, long term goals – use imagery to build a
preferred future or connect with healthy parts of self from past
(What would you like…… What would it look like if..?)
• Lack of resources – build support system, understand needs
• Psychotic symptoms – CBTp strategies

33. Complementing Medications: The Whole
Person
By Dr. Tomas Fogl, Psychiatrist, Schizophrenia Program

34. Video
www.thisvideo.ca

35. The Stigma of Mental Illness
Functions, consequences and … what next ?
By Anik Gosselin, Ph.D., C.Psych.
Clinical Psychologist and Forensic Neuropsychologist
Forensic Treatment Unit, Brockville
The Royal

36. Prejudice vs Stigma
Prejudice: Antipathy based upon a faulty and inflexible
generalization. Directed toward a group as a whole or toward
an individual because he is a member of that group (Allport,
1954) focus on perpetrators
•e.g., race and ethnic groups
Stigma: Situation of the individual who is disqualified from full
social acceptance. The stigmatized individual is reduced in our
minds from a whole and usual person to a tainted, discounted
one (Goffman, 1963) focus on targeted individuals
•e.g., mental illness

37. Three Functions of Stigma and Prejudice
(Phelan, Link & Dovidio, 2008)
1. Exploitation/domination (i.e., keeping people
down) – e.g., racism
2. Enforcement of social norms (i.e., keeping
people in) – e.g., obesity, smoking,
homosexuality, criminal behaviour
3. Avoidance of disease (i.e., keeping people away)
- e.g., mental illness, mental retardation

38. Effects of Stigma on the Targeted Individuals
• Depression, demoralization, shame (Lucksted et al., 2011)
• Social avoidance, distancing (Link et al., 2004)
• Increase in symptom intensity (Livingston & Boyd, 2010)
• Increase in hospitalization, decrease in engagement (Kvrgic et al.,
2013)
• Decrease in hope and in quality of life (Mittal et al., 2012)
• Decrease in treatment adherence and in help-seeking (Vogel et al.,
2013)
• Poor self-esteem and self-efficacy

39. Progressive Model of Self-stigma
(Corrigan & Rao, 2012)
AWARENESS
•“The public believes people with mental illness are weak”
AGREEMENT
•“That’s right. People with mental illness are weak.”
APPLICATION
•“I am mentally ill so I must be weak.”
HARM
•“Because I am weak, I am not worthy or able.”
WHY TRY…
to pursue a job: I am not worthy….to live on my own, I am not
able.

40. The Why-try Effect(Corrigan et al., 2009)
Stereotypes
Blame
Dangerousness
Incompetence
Fewer
behaviours in
pursuit of
goals!
Decreased
participation in
evidence-
based
practices
Public
Stigma
Self-Stigma
Awareness
Agreement
Application
Social
Mediators
Self-esteem
Self-efficacy

41. Stigma in Forensics – an additional
challenge to recovery
• The forensic label: a double stigma
‘I am violent and mentally ill; I scare people, I am not
worthy of love; I have to hide’
• Housing difficulties

42. What Next?
At the societal level:
•Policy and law changes - make discrimination illegal (e.g.,
refusing a job or housing based on history of mental illness)
•Decrease ignorance and preconceived ideas
– Outreach to the public (e.g., a person with a mental illness comes and
talks to different groups from the community)
•Talk about it!
For the stigmatized individuals:
•Join peer support groups
•Disclose
•Promote personal empowerment

43. Disclosure Strategies
(Corrigan & Rao, 2012)
Social Avoidance
Stay away from people so they don’t have a chance to stigmatize me
Secrecy
Go out into the world – work and go to church, but tell no one about my
illness
Selective Disclosure
Tell people about my illness who seem like they will understand
Indiscriminant Disclosure
Hide it from no one
Broadcast
Be proud - Let people know

45. Peer work and CBT
Presented by:
Carlo Verdicchio, Peer Support Worker
The Royal

46. My Role
1. Offering Support

47. 2. Holding Hope

48. 3. Exploring Recovery
Remember: it looks different for everyone.
Horizon Hope by Laura Harris

49. Peer Support in Recovery
“Research findings document that individuals who use peer run
services have decreased hospitalizations, suicide rates, and substance
use, an increase in social contacts, ability to carry out activities of daily
Living and a positive impact on participants’ recovery, including an
increase in their empowerment, hopefulness, and informal learning of
adaptive coping strategies.”
J. Campbell in On Our Own Together: Peer Programs for People with
Mental Illness:

50. Wellness
From the December 2012 issue of the Canadian Foundation for
Healthcare Improvement’s Mythbusters :
“…a growing body of evidence is showing that recovery of
meaningful life despite limitations imposed by illness is possible
and likely. People with lived experience have known for some
time that, with hope, empowerment and support from others,
recovery is possible. Promoting a mental health system that
views both personal and clinical recovery as the objective can
reduce the healthcare costs, enhance quality of life, promote
social inclusion, and help those living with mental illness lead full
and productive lives.”

51. WRAP and Recovery
By Tiffany Clough

52. Resources
By Sandra Jacquens, MSW, RSW
Social Worker, Schizophrenia Program
The Royal

53. Resources for families and their loved ones
The Royal
A physician referral is needed for assessment in the Consultation Clinic or to request ongoing
treatment. Website: www.theroyal.ca
Program Eligibility Criteria – Schizophrenia Program
• Are aged between 18 to 65
• Have a working diagnosis or symptoms of Schizophrenia or a Schizoaffective Disorder
• Have clinical needs that cannot be adequately addressed in the community or the general
psychiatry setting, defined as:
– Unstable symptoms or failure to respond well to medication
– Psychosocial needs in at least three of the following five areas:
– Basic tasks of independent living
– Housing
– Finances
– Educational or occupational functioning
– Ability to establish or maintain social support system
• Have at least one of the clinical needs listed above and/or would benefit from clinical research
activity in the Schizophrenia Program

54. Resources for families and their loved ones
Champlain District Regional First Episode Psychosis
Program – On Track (bilingual)
Accepts individuals aged 16 to 35 years who are experiencing
symptoms of psychosis who have:
• less than six months of prior treatment, and
• symptoms that are not explained by drug abuse or other mental
health problems
613.737.8069 or 1.888.737.8069
Bank Street Professional Centre
1355 Bank Street
Suite 208
Ottawa, Ontario
K1H 8K7

55. What to do in a crisis
• Contact your doctor
• Go to the nearest hospital emergency room
• Call 911
• Telehealth Ontario: 1-866-797-0000 (24 hours/day)
• Ontario Mental Health Helpline/Ligne d’aide sur la santé mentale:
1-866-531-2600
• Youth Services Bureau (YSB) Crisis Line: 613-260-2360 (bilingual)
• Mental Health Crisis Line in Ottawa: 613-722-6914 or outside
Ottawa: 1-866-996-0991

56. How to acquire a psychiatric assessment
When a person appears to be suffering from a mental disorder, but is
unwilling to obtain help, a mental health assessment may be
necessary. There are options for people who want to get an
assessment for someone who is refusing to have one voluntarily.
•Convince and support the person to get an assessment
•By order of a physician
•Justice of the Peace Order (Form 2)
•Once a Form 2 is issued
•If Form 2 is not issued

57. A Guide For Families and Individuals
Navigating The Addictions And Mental Health
System In Champlain
(www.f-a-c.ca)
Shortcut to photo.JPG.lnk

58. Handouts Available
• Community Counselling Resources
• Key Family Information and Support Resources in Ottawa
• Family Information and Support Meetings (The Royal)
• Family Education Series (The Royal)

59. References for Clients
• Freeman, D., Freeman, J., & Garety, P. (2008). Overcoming paranoid and
suspicious thoughts: A self-help guide using cognitive behavioral techniques.
New York: Basic Books.
• Hayward, M., Strauss, C., & Kingdon, D. (2012). Overcoming distressing
voices: A self-help guide using cognitive behavioral techniques. London, UK:
Constable & Robinson.
• Morrison, A. P., Renton, J. C., French, P., & Bentall, R. P. (2008). Think you’re
crazy? Think again: A resource book for cognitive therapy for psychosis. New
York: Routledge / Taylor & Francis Group.
• Turkington, D., Kingdon, D., Rathod, S., Wilcock, S. K. J., Brabban, A.,
Cromarty, P., et al. (2009). Back to life, back to normality. Cambridge, UK:
Cambridge University Press.
• Quintal, Marie-Luce et al. Je suis une personne pas une maladie ! La maladie
mentale : l’espoir d’un mieux-être. Performance Édition. Québec. 2013 (not
CBT specific but excellent référence générale sur le sujet)

60. References for Professionals
• Beck, A. T., Rector, N.A., Stolar, N., & Grant, P. (2009). Schizophrenia: Cognitive theory, research, and
therapy. New York: Guilford Press.
• Beck, J. S. (2011) Cognitive behavior therapy : basics and beyond. New York: Guilford Press.
• Byrne, S., Birchwood, M., Trower, P., & Meaden, A. (Eds.) (2006). A casebook of cognitive behaviour
therapy for command hallucinations: A social rank theory approach. New York: Routledge / Taylor &
Francis Group.
• Gilbert, P. (2010). Compassion-focused therapy. New York: Routledge, Taylor & Francis Group.
• Kingdon, D. G., & Turkington, D. (2005). Cognitive therapy of schizophrenia. New York: Guilford Press.
• Meaden, A., Keen, N., Aston, R., Barton, K., & Bucci, S. (2013). Cognitive therapy for command
hallucinations: An advanced practical companion. London, UK: Routledge / Taylor & Francis Group.
• Morris, E. M., Johns, L. C., & Oliver, J. E. (Eds.). (2013). Acceptance and commitment therapy and
mindfulness for psychosis. Chichester, UK: Wiley-Blackwell.
• Nelson, H. (2005). Cognitive-behavioural therapy with delusions and hallucinations : a practice manual.
Cheltenham, U.K.: Nelson Thornes.
• Tarrier, N., Gooding, P., Pratt, D., Kelly, J., Awenat, Y., & Maxwell, J. (2013). Cognitive behavioural
prevention of suicide in psychosis: A treatment manual. London, UK: Routledge / Taylor & Francis
Group.
• Willson, R. & Branch, R. (2006). Les thérapies comportementales et cognitives pour les nuls. Paris-
France: Éditons First.
• Wright, N.P., & al. (2014) Treating Psychosis. Oakland, CA: New Harbinger Publications, Inc.
www.treatingpsychosis.com
• Willson, R. & Branch, Rhena. Les Thérapies Comportementales et cognitives pour les nuls. Éditions
générales First. France. 2006 (not CBT for psychosis specific)

61. Q & A Session