An Introduction to Cognitive Behavioral Therapy for Psychosis - - PowerPoint PPT Presentation

An Introduction to Cognitive Behavioral Therapy for Psychosis (CBTP)

Rebecca Jaynes, LCPC Sarah Lynch, LCSW Meredith Charney, Ph.D Cori Cather, Ph.D

Webinar June 22, 2020 2:00-4:00PM Maine Medical Center/PIER Program

Workshop Agenda

1. Why CBTp? 2. CBTp- Phase 1- Engagement & Introducing the model 3. CBTp-Phase 2- Assessment and Goal-Setting 4. CBTp- Phase 3- Approaching problems through: 1. Coping Skill Enhancement 2. Cognitive Restructuring (CR) *Case Example and Trainer demonstration at each phase of treatment

Poll

• Do you currently work with clients with

psychosis?

• Do you use a form of CBT in your practice?
• CBT for depression/anxiety
• Trauma-focused CBT
• Mindfulness-based CBT
• CBT for psychosis

Why CBTp?

• People with psychosis want to and can play an

active role in their treatment

• Many people with psychotic disorders continue to

have psychotic symptoms and specific interventions to target these symptoms are warranted

• CBTp improves psychotic symptoms and

decreases distress

Research supports CBTp

• Evidence base for CBTp is statistically stable

and sufficient

• CBTp particularly effective for hallucinations
• Meta-analyses have also shown small to medium

effects on delusions, general and negative symptoms

Meta Analysis of RCTs Comparing Efficacy of CBTp to Control Treatment on Hallucinations and Delusions (N = 2407)

0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.34 0.37 0.34 0.23

• vs. TAU--

hallucinations

• vs. TAU--

delusions

• vs. AC--

hallucinations

• vs. AC-

delusions

Effect size (g) (Turner, SZ Bull, 2020)

TAU = treatment as usual; AC = active control

Who Does the Research Apply to?

• Participants who are willing and able to give

informed consent

• Most studies conducted with outpatients
• Most are help-seeking
• Participants have residual distressing psychotic

symptoms despite some treatment with antipsychotic medication

Overarching Goals of CBTp

• Foster a curious attitude about symptoms
• Decrease distress associated with symptoms
• Adopt “living with illness” strategy
• Improve sense of personal control
• Enhance healthy, effective coping with

symptoms

• Improve day-to-day functioning
• Prevent relapse

Treatment Phases of CBTp

• Phase 1: Engagement and Intro to CBT
• Phase 2: Assessment and Goal Setting
• Phase 3: Approaching problems on the problem

list

• Phase 4: Generalization of Skills and Progress

Tracking

• Phase 5: Relapse Prevention

Session Structure of CBTp

• Set agenda together
• Homework review
• Symptom/functioning check
• Introduce and practice new skill
• Psychoeducation
• Collaborative homework assignment

(Be prepared with handouts, write everything down, keep agenda manageable)

Case Example: Elizah

• 19 year-old female, Caucasian, visual artist,

creative

• Referral symptoms– Longstanding visual

hallucinations, recent auditory hallucinations, delusional thoughts, SI/HI

• Functional difficulties– Not working or in school

Phase 1: Engagement and Intro to CBTp

• Therapeutic alliance
• Introduction to CBTp
• Teach Cognitive Model
• Examine how you think about a situation
• How you act based on your thoughts
• How your thinking and behavior together

affect how you feel

• Normalization and Psychoeducation

Phase 1: Creating a Therapeutic Alliance

• Convey specific expertise and hope related to

recovery from psychosis

• Empathize with distress and do not collude with

delusional beliefs

• Encourage client to share paranoid beliefs about

you

• Normalize and destigmatize psychosis

Trainer Demonstration –

• Session Structure, Introducing CBTp (brief)

Phase 2: Assessment and Goal Setting

• Assessments and measures to establish

baseline and track progress

• Case Formulation – Begin “Making Sense”

(Active process documented over time – puts current concerns in context of person’s history, strengths, stressors, thought/feeling/behavior patterns)

• Develop Problem and Goal List

Evolution of Elizah’s Delusion

“I’ve always been creative. I’d see creatures in the closet and in corners as long as I can remember…I just thought everyone did.” “Earlier this year, my grandmother died. I started having nightmares about her dying. I was depressed, my art got dark, and I started seeing these spirits from the

• nightmares. I’d see them everywhere, they’d talk to me, tell me I was evil

too. Everything was falling apart, I stopped sleeping because of the nightmares and voices and spirits. I realized then that this evil in my dreams was in me. I was the evil one, and I must have caused her death” “And then my girlfriend broke up with me, I was so hurt. The evil voice took over and made me threaten to kill her…then I got so scared. I thought, “I could have killed her too” So I hid away in my room, to keep everyone safe.

“I have an evil spirit in me” “I am dangerous to

• thers”.

Formulation of Elizah’s Difficulties

Situation: 1) GM death 2) Break up with girlfriend Voices: “You caused her to die” “She deserves to die too” “Kill her” Thoughts: “I am dangerous” Feelings: Scared, powerless, lonely Behaviors: stay in my room to keep others safe

Underlying Concerns/Core Beliefs: “I’m evil inside” I’m dangerous to other people” Functional Challenges: Can’t be around people฀ unable to work, go to school, be in public

Case Formulation

“Making Sense”

• Living document—added to over time
• Provides a platform for education about role of

trauma and stress vulnerability model

• Depending on client, could share a pared down
• r full version
• Some clients will have making sense as a goal;
• thers will respond to this as a way of figuring
• ut how to individualize CBT to their particular

life situation

Predisposing factors

SOCIAL

Current concerns

UNDERLYING CONCERNS

Precipitating factors Perpetuating factors Protective factors

PHYSICAL

• ACTIONS

FEELINGS THOUGHTS

Making Sense

Courtesy of Dr. David Kingdon

“Making Sense” Components

“The 4 P’s” Predisposing: vulnerabilities such as genetic/biological/familial factors; childhood trauma Precipitating: factors occurring right before the episode: increased stress, drug use, trauma, life change Perpetuating: factors that maintain the symptoms & problems: substance use, safety behaviors, family issues Protective: positive traits/behaviors or resilience factors: medication adherence, family support, personality factors

“Making Sense” Components (cont’d)

Current Concerns: client’s own words; tie to problem/goal list eventually Thoughts/Feelings/Actions: typical, frequent patterns related to symptoms and other problems (“The voices are going to harm me”/Scared/Close curtains and stay in all day) Social/Physical: perceived challenges; can be beliefs

• r specific symptoms/concerns/problems

Underlying Concerns: the heart of client’s negative affect; core beliefs about self, others, and world that perpetuate psychotic and other symptoms

Trainer Demonstration: Making Sense

Predisposing factors

• -Longstanding

illusions/hallucinations

• -Creative/visual
• -Isolated
• -Don’t ask for help
• -Limited coping skills

SOCIAL

• -No friends
• -Avoids interactions, even with family

Current concerns 1) Am I evil? 2)Am I safe/in control? 3)Am I capable of working/being in a relationship (safely)? UNDERLYING CONCERNS/ CORE BELIEFS “I’m weak.” “I’m flawed/something is wrong with me.” “I am a bad person.” I’m crazy/out of control” “I can’t trust myself” Precipitating factors

• -Death/breakup
• -Loss/rejection
• -Feeling out of control
• -Depression
• -Fear of intimacy

Perpetuating factors

• -Feeling weak, alone
• -Not asking for help
• -Too much art to cope
• -Isolating
• -Engaging with the voices

Protective factors

• -Doing things that make

me feel strong (selling art, posting online, speaking

• ut)
• -Asking people I love for

help

• -Not seeing myself as

crazy PHYSICAL

• -Feel unhealthy

ACTIONS

• - Stay home (isolate)
• -”Disconnect”
• -Isolate
• -Hurt myself to make the voice stop

FEELINGS

• -Scared
• -Powerless
• -Incapable
• -Lonely

THOUGHTS “I’m evil inside” “I am dangerous to others”

Making Sense-Elizah

Courtesy of Dr. David Kingdon

Phase 2 Continued: Developing A Problem List And Goals

Develop a Problem/Goal List

• Collaboration is key
• Use client’s own words
• Assess what is most important to guide goal

development

• Prioritize and maintain focus on function
• Include at least one goal related to a psychotic

symptom

Elizah’s Problem List

Identified areas of concern: 1. I want to keep others safe from the evil. 2. I want to keep the evil under control. 3. I want to be able to do things again, like work. Goals: 1. Learn ways to keep myself and others safe. 2. Learn ways to feel more in control of my emotions and behaviors. 3. Learn ways to live with difficult experiences, to become more independent (get a job).

Ongoing Assessment

Assessment as an Engagement Strategy

• Conveys expertise
• Sets the stage for self-monitoring and self-

awareness; “distancing” from the experiences

• Helps to make sense of confusing experiences
• Guides case formulation and focuses the

treatment to be person-centered

• Provides objective feedback on whether CBTp is

beneficial

• Allows for the celebration of progress and

increases sense of control over life and symptoms

How To: Assessment

• Provide rationale for measurement-based care
• Choose at least one outcome measure to

administer at baseline (or close to) while maintaining engagement and follow forward with that measure

• Refrain from apologizing for assessment, rushing

through or minimizing importance

• Share results of assessment and check for fit

with client’s subjective sense

Specific Measures

Domain

Scales

Paranoia

P-Scale PSYRATS SAPS

Hallucinations

BAVQ-R PSYRATS SAPS

Depression CDSS PHQ-9 BDI-II Overall BPRS PANSS Negative Symptoms SANS Trauma PCL OCD Y-BOCS Anxiety GAD-7 BAI

Brief Assessment of Voices Questionnaire

For Elizah, BAVQ helped to

• Articulate and track progress
• See changes over time
• Make predictions/recognize patterns
• 4 subscales

Over time….

• Malevolence – HIGH

LOWER

• Benevolence – LOW

SAME

• Omnipotence – HIGH

LOWER

• Resistance – HIGH(complex)

MIDRANGE

• Engagement – HIGH

LOWER

Trainer demonstration-brief

Incorporating/reviewing assessments and coping strategy enhancement?

Coping Strategy Enhancement

“A living with… while working on” approach

Rationale for Coping Strategy Enhancement

• Inclusive and accessible
• Does not require “insight”
• Expresses empathy
• Focuses on distress, which is universal
• Infuses optimism
• Together you can optimize coping
• Normalizing: others can do it and so can I

People who ‘cope well’ with voices:

• Experienced themselves as stronger with

respect to voices and to their environment

• More positive voices, less imperative voices
• More able to set limits to voices
• Communicated more often about the voices
• Used fewer distraction techniques

(Romme & Escher, 1996)

Assess Current and Past Coping Responses

• Focus on Distress
• Keep a log
• Identify triggers and secondary thoughts
• Focus in on the experience
• Try new skills
• Review your strengths
• Consider different types of coping
• Behavioral, cognitive, affective

Behavioral Coping Strategies

• Responding with awareness
• Change your location
• Develop a routine– tea kettle
• Go for a walk
• 5 senses grounding
• “Sensory switch”
• “Look point name”
• “Check it out”– with a recovery partner

Cognitive Coping Strategies

• Focus on thoughts as a result of the experience
• Look for your “thought traps” (CST)
• Develop a mantra
• “Drop and give me 5”
• Use hallucination scheduling
• Use cognitive restructuring skills

Affective Coping Strategies

• Focus on managing intense feelings
• Identify emotional reasoning
• Use distress tolerance skills
• Use grounding techniques
• Wave Imagery

Elizah’s Log-1

Situation What did you hear? How did you respond? How effective? Tried going to apply for a job “You can’t be trusted” “Someone’s going to get hurt” Left & went home, journaled Not at all A little Some A lot

Elizah’s Voice Coping Log-2

Situation What did you hear? How did you respond? How effective? Tried going to apply for a job (next day) “You can’t be trusted” “Someone’s going to get hurt” Walked around block, 5 sense grounding, WENT IN Not at all A little Some A lot

Cognitive Restructuring (CR)

CR is More Than “Reality Testing”

Other common CR targets:

• Beliefs about one’s own power and that of

voices/persecutors “I am powerless.”

• Negative core beliefs “I am a failure.”
• Internalized beliefs related to illness “I will never

make anything of myself because I have schizophrenia.”

• Beliefs about medications and treatment

“Taking medication/therapy is a sign of weakness.”

Laying the Foundation for CR-Based Interventions

1. The Thought-Feeling (T-F) Model 2. Alternative Explanations 3. Common Styles of Thinking

• 1. The Thought-Feeling Model
• Social Isolation
• Avoidance
• Hypervigilence
• Safety Behaviors

Thought s Behavior Emotion s

• I’m in danger
• People cannot be

trusted

• I’m an outsider
• People want to hurt

me

• Paranoia

• 2. Alternative Beliefs Exercise
• Start with neutral scenario, then progress to one

related to the client’s psychosis (individualized)

• Purpose is to enhance cognitive flexibility, not to

get to “the truth”

• Also can be used to reinforce the thought-feeling

model

Neutral Item: “Clerk at Dunkin Donuts gives you hot coffee when you ordered iced coffee.”

• She didn’t hear me correctly.
• The ice machine was broken.
• She is trying to send me a message that the

demons are coming for me.

• She is tired because she is sick so she her brain

is not working well.

• She has her manager watching her today and

she is nervous which is making her make mistakes.

• I thought I said iced coffee, but I actually said hot

coffee.

Individualized Item: “The newscaster looks right at the camera and says “Dan.”

• He is talking to me because I can forecast the

weather.

• He is talking about someone famous named

Dan.

• He is calling the camera man named Dan and it

wasn’t supposed to be caught on tape.

• Someone in the other room called my name and

I misheard it as coming from the TV.

• He was saying a different word like Taliban that

sounded to me like Dan.

• 3. Common Styles of Thinking
• You may recognize these as “cognitive

distortions”

• Examples: Catastrophizing, Overestimation of

Risk, Emotional Reasoning

• 4. 5 Steps of CR
• Step-by-step format that allows for the possibility

that the evidence will support the distressing thought

• Provide hints using Socratic questioning (“What

would you say to a friend who said this?”)

• Remind client about criteria for good evidence

especially over time as they learn the skill

Trainer Demonstration: 5 Steps of CR

Starting CR: 5 Steps Format

Elizah– Cognitive Restructuring Over Time

Old Thought CR Reframed Thought Related Functional Gain

“I am evil.” “The voice doesn’t define me, I define me” Join peer support

• group. Pursue goal of

applying for a job. “If I’m not careful, I will hurt someone (physically).” “I do not act on these

• thoughts. I am a gentle

person.” Starts a relationship. Is

• pen about MH

struggles. “If I’m not careful, I might end up hurting

• thers/getting hurt

(emotionally)” “Getting close to others is worth the risk of getting hurt.. ” Begins to get closer to her partner and starts part-time job. Involves girlfriend in her treatment as a recovery partner.

Elizah’s Relapse Prevention Plan

• Watch for: stress, sleep change, big life changes,

intimacy fears.

• What to do in the moment: mantra, break, 5

sense grounding, 5 steps of CR.

• What to do to take care of myself– talk it out with

my recovery partner, journal, talk to my MD about meds, start tracking my mood, energy, sleep again. Don’t panic.

• Why do this– because I’m not evil, this is not my

fault, I can be creative and hear voices and be

• OK. I have not and will not act on these voices. I

will not be afraid, I am not evil.

Take Aways

• Develop an alliance through normalization and

psychoeducation

• Shared conceptualization of symptoms
• “Making sense” formulation is a live document that

gets updated throughout the course of treatment

• Strategies are cognitive restructuring and coping

strategy enhancement

• Cognitive Restructuring is more than “reality testing
• Relapse Prevention planning is an ongoing process

Next Steps

• Are you interested in future CBTp trainings?
• Are you interested in joining a CBTp learning

collaborative (i.e., consultation/supervision group)?

• Would you be interested in becoming a CBTp

provider listed in the directory we are building?

Thank you for your participation! Questions/ Comments? Next Steps