Cognitive Behavior Therapy(CBT) for PsychosisBasic 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 DisordersMeredith L. Draper, Ph.D.

Assistant Professor, Department of PsychiatryUniversity of Texas Health Science Center, San Antonio

Supported by grant # R01 MH082793

Cognitive Behavior Therapy for Psychosis (CBTp)

• Serious mental illness and the criminal justice system

• Understanding psychosis

• Basic CBT techniques

Serious mental illness and the criminal justice system

Serious Mental Illness (SMI) and Criminal Justice Involvement

• Research indicates that 15-24% of U.S. inmates have severe mental illness (Baillargeon, et. al., 2009)

• Rates tend to be higher for women than men

• Individuals with SMI experience 3 to 6 times the rate of incarceration than the general population (U.S. Dept. of Justice, 2009).

Judicial Involvement of Individuals with Psychosis

• According to the Department of Justice, 15%-24% of all prison and jail inmates respectively report psychotic symptoms (Lamberti, 2007)

Recidivism of Individuals Diagnosed with an SMI

• A recent retrospective study of Texas Department of Criminal Justice statistics indicated:– 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).

When incarcerated…..

• Studies show that individuals with SMI frequently do not receive adequate psychiatric treatment (Lamberti, 2007)– They are not identified– Receive only medication treatment while in

custody– May not follow up with or be connected to

ongoing services when released

A Review of schizophrenia and psychosis

Schizophrenia: Signs and symptoms related to outcome

Schizophrenia: Signs and symptoms related to outcome

Negative Symptoms Affective BluntingPoverty of speechAmotivationDecreased activitySocial withdrawal

Cognitive DeficitsAttentionMemoryExecutive functions

Comorbid ConditionsMood Substance abuseAnxiety

Community FunctioningWork/School

Interpersonal relationshipsSelf-care/ADLs

Positive SymptomsDelusionsHallucinationsDisorganized speech/behavior

Living with SchizophreniaCognitive deficits lead to problems with organization and planning….

Symptoms can cause…

Isolation Family/social conflict

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

5

10

15

20

25

0 1-10 11-30 >30

Partial Compliance and Hospitalization P

ati

en

ts h

osp

italized

(%

)Studies with better methodology demonstrate that patients takeAbout 50% of prescribed medication

How might you spot someone with SMI? What does psychosis look

like?People with psychosis People without psychosis

Dichotomy or Continuum?

• We all have experiences and/or beliefs not understood by others– The extent to which an individual is convinced

of the belief may differ– The effect that the belief has on daily

functioning may differ

• Understanding this continuum is essential for being able to apply CBT techniques

Continuum of Experience

Normal thoughts

Imagination Dreams Delusions and hallucinations

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…

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%

Politics Today

• Individuals on the right cannot understand the beliefs of those on the left

• Individuals on the left cannot understand the beliefs of those on the right

• Each side has individuals with full conviction who believe they are 100% correct and the other side is 100% wrong

• Beliefs are strongly defended and each bit of evidence is weighed differently by different sides

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

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 "voices" would tell him to "sit here" or "sit there?" (Funk & Wagnalls Encyclopedia, 1990, "Hallucinations.")

Normalizing:Famous Voice Hearer: Winston Churchill

http://www.intervoiceonline.org

Developing an Understanding of the Voice Hearing Experience

GROUP EXERSIZE

What if you heard voices and were in crisis?

• We know that the stress can exacerbate psychotic symptoms.– Voices– Delusions – Disorganized Thinking

Circumstances leading to hallucinations in the general

population

• Waking up or falling asleep

• Sensory deprivation

• Substance use

• Sleep deprivation

• Bereavement

What leads to a diagnosis?

• Having a hallucination does not lead to a diagnosis

• 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

A Review of Psychosis• Many individuals treated with antipsychotic

medications continue to experience delusions and/or hallucinations.

• These persisting positive symptoms can be extremely distressing and negatively impact daily functioning.

Sensky et al., 2000; Kane & Marder, 1993; Pantelis & Barnes, 1996; Wiersma et al., 1998; O’Connor & Herman, 1993; Cather et al., 2004

SMI and Trauma

• Individuals with SMI have a high prevalence of trauma histories and post traumatic stress disorder (PTSD) (Lommen & Restifo, 2009)– 30-40% of patients experiencing psychosis meet

criteria for PTSD (Mueser, et. al., 2002)– 13-29% of individuals with schizophrenia are

diagnosed with comorbid PTSD– Individuals with SMI are more likely than the general

population to be victims of crime (Levin, 2005)

Overview of Cognitive Behavioral Therapy for

Psychosis

Cognitive Behavioral Therapy for Psychosis

• A brief description of CBT for psychosis

• A model to understand the creation, maintenance and exacerbation of psychotic symptoms

• Efficacy of CBT

• Techniques to use with individuals experiencing psychosis in crisis situations

Cognitive Behavior Therapy• Pioneered in the U.S. by Aaron Beck• 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.

(Beck, 1952)

Theoretical Framework of CBT

• Stress-Vulnerability model

• Reasoning and appraisal biases

Stress-Vulnerability Model of Psychosis

Stress-Vulnerability Model

Money Problems

Relationship Break-up

Stress-Vulnerability Model

Money Problems

Relationship Break-up

AssaultSubstance Use Fight with

bossSpeeding

Ticket

This is often the state during an encounter with law enforcement

Stress-Vulnerability Model

Money Problems

Relationship Break-up

AssaultSubstance Use Fight with

bossSpeeding

Ticket

Medication

Family Support

Someone to listen

Regular Sleep

Emotional Processes contributing to the development and maintenance of

positive symptoms• We know that psychoses are partly genetically

determined: Stress-Vulnerability Hypothesis• Under stress, individuals who have an inherited

genetic vulnerability will go on to develop psychotic symptoms.

• The content of delusions and hallucinations can vary greatly by individual and is partly determined by their unique emotional experiences.

• The more you understand about the individual the more you can help

Symptoms come from Information Processing Deficits and Reasoning

Biases• 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.

• Information is then interpreted in light of these pre-existing models. Confirmatory evidence is weighted more heavily.

85:15 ratioThe Beady Task

•Pull out a series of beads one at a time using only 1 jar•Ask when the person is convinced about which jar the beads came from

Beads seen before deciding! (Dudley et al.,

1997a)

0

1

2

3

4

5

6

7

8

9

85:15 ratio 60:40 ratio

DelusionsDepressionControls

Cognitive Behavior Therapy

• Focus on those with continuing psychotic symptoms despite optimal (or sometimes not) medication treatment.

• Aims to reduce the intensity of delusions and hallucinations and related distress.

• Interventions focus on rational exploration of psychosis, challenging beliefs, reality testing, develop coping strategies.

Efficacy of CBT

• Meta-analytic studies support efficacy of CBT, especially in treatment of positive symptoms in chronic patients.– Gould et al (2001)

– Rector & Beck (2001)

– Pilling et al (2002)

– Tarrier & Wykes (2004)

– Zimmerman et al (2005)

– Wykes, Steele, Everitt & Tarrier (2008)

Status of CBTp in the treatment of psychosis (Tarrier & Wykes, 2004)

• Identified 20 trials that have a control group, the majority randomised, that have evaluated some ‘brand’ of CBT to treat schizophrenic patients.

• All are one-to-one therapy.• All assess positive psychotic symptoms in some way.• 739 patients treated with CBTp with a mean of 37 treated

in each study (sd=48, range 7-225).• mainly chronic patients (17/20) outpatients (16/20)• Acutely ill patients (3/20)• 16 in UK, 1 each from Canada, Holland, Italy, & USA

Effect Sizes from CBTp studies (post-treatment CBTp/control)

-0.6

-0.4

-0.2

0

0.2

0.4

0.6

0.8

1• Data available from 19

studies.

• Mean ES =0.37 (sd=0.39, median=0.32, range -0.49 to 0.99).

• 74% achieved at least a small ES,

• 32% a least a moderate ES,

• 16% a large ES

Example studies

• 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%).

Responders to 9 months of CBT versus Standard Care

50

31

0

10

20

30

40

50

60

CBT Standard Care

Per

cent

Res

pond

ing

Kuipers et al. (2006)

35.6

20.5

15.1

36.6

22.9 26.6

10

15

20

25

30

35

40

CBT

ActiveControl

Baseline 9 months 18 monthsTreatment Phase Follow-up

Sym

ptom

s

CBT versus an active comparator treatment

Sensky et al.,2002

CBT for Law Enforcement

• Helps to understand the individual’s perspective, how they think and feel

• An understanding and application of CBT approaches can help to deescalate crisis situations

Techniques Informed by CBT for Psychosis

Techniques • Making a connection

– How to engage someone experiencing psychosis

• Normalizing– Focus reducing stigma

• Formulation– How to make some sense of psychotic experiences

• Crisis Management– Deescalating someone who is psychotic

Engagement • Awareness of STIGMA:

– 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.

– 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.

Engagement

• Oftentimes individuals experiencing psychosis are used to being put off or not heard

• Consumers with long histories of mental illness report never being asked questions like “How did all this start?”

• Awareness of cultural values – may impact the understanding (positive or

negative) of psychotic symptoms

Formulating (Making Sense)Trigger

Psychotic Symptom

Belief about symptom

Consequence Behavior

Formulating (Making Sense)Fight with Mom about medicine

Hear a voice

Mom is trying to poison me

FearNo sleep

Threatens to hurt mom, she calls the

police

Many patients state that the brain disease model degrades and demoralizes them

Automatic thoughts

• Others will despise me!

• I will be a burden!

• There is utterly nothing good about this!

• There is no hope!

• I will deteriorate and end up on the streets!

• Everyone is trying to hurt me.

• Emotions dread, despair and anger.

Normalizing: the antidote to Stigma.• Normalizing is a technique for engaging with the

individual

• The goal is to avoid catastrophizing and understand that:– Virtually everyone faces a significant illness at some

point in their life– Their experiences are more common than they may

realize and are a struggle that affects many people in many cultures

– The illness is not anyone’s fault– A large number of people overcome most symptoms

Normalizing • 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.

Best normalising explanations of voice hearing

• Bereavement• Trauma• Lack of sleep• Para-psychological• Shamanistic• Brain biology and

stress.

Symptoms e.g. hearing voices

Worry e.g.‘I’m going crazy’‘I’m in danger’

Feel upset, anxious,

depressed etc

Symptoms get worse

Normalizing Exacerbation of Psychotic Symptoms

Client Comments and Normalizing Responses

• “I know you’re going to take me to jail because I hear voices”.

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.

Client comments and Normalizing Responses

• I will be locked up in a hospital forever.

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.

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.

• Only crazy people hear voices.

Help for people with delusions: Basic Socratic questions to

diffuse agitation• Colombo style questioning

• E.g. What would happen if you woke up with green spots covering your legs?– How would you feel?– What might you think?– What would you do? – What would you need?

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

AllergiesColdsSmokerDirected at me

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

911 call from a woman complaining of a home invasion

• A woman reports has just returned home and her house has been broken into.

• 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.

• How would you handle this?

Ride the Bus-Don’t allow safety behavior

Ride the Bus-Don’t allow safety behavior

Ride the Bus-Don’t allow safety behavior

Sometimes delusions can bolster self-esteem

• In this case it is important to help the individual find a realistic basis for accomplishment and self esteem

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.”

Choosing your words

• Individuals experiencing psychosis are used to having to defend their ideas and to being patronized.

• Do not directly confront their beliefs ideas.

• It is equally important not to collude with them.

Choosing your words • 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.”

• The first phrasing implies that the CIA is actually following the patient, where as the second suggests that this a thought the patient has.

• 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.

Do not seize upon doubt expressed by the patient immediately

• 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.

• 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.”

Conclusions

• Simple things to do to diffuse situations

• Try to make sense of the person’s experience

• Normalize