Transcript Cognitive Therapy for Psychosis Presentation

Cognitive
Therapy for
Psychosis
Presenter: Ron Unger LCSW
The Essential idea of CognitiveBehavioral Therapy:
 If
you learn to think and act differently,
then your mental and/or emotional
problems can disappear
 You
are the one who is responsible for
changing thoughts and behaviors, though
others may help you figure out how to do it
Language from official US
government website:
 “What
causes schizophrenia?
 “Schizophrenia is nobody’s fault. This
means that you did not cause the disorder,
and neither did your family members or
anyone else. Scientists believe that the
symptoms of schizophrenia are caused by
a chemical imbalance in the brain.”
Shame and
Blame model:
“you must have
chosen to
become like this
and you could
chose to get over
it if you want to –
pull yourself up
by your
bootstraps”
Cognitive
model: “You
aren’t to blame
for falling into
this problematic
pattern, you
didn’t know
enough to
anticipate it, but
with effort and
with help you
may learn to get
out of it”
Medical model:
“You have a
brain disease
and/or a
biochemical
imbalance: you
aren’t
responsible, your
thoughts &
decisions played
no role in this”
Cognitive therapy for psychosis
 Is
a systematic approach
 Is well researched


At least 23 randomized studies
Is considered an “evidence based practice”
 Being
systematic and “evidence based”
provides some weight when attempting to
push back against the “medical model”
Cognitive Therapy and Medications

The evidence base is mostly with clients who
also took medications


Cognitive therapy worked to reduce the symptoms the
medication did not control
As a result of cognitive therapy, clients are often
able to use less medication
 Case study reports show cognitive therapy is
often helpful with clients who refuse
medications.
 One research study showed cognitive therapy
alone was effective in reducing risk for people
just starting to experience psychotic symptoms
How does it work?
 A collaborative,
respectful relationship is
key

Therapist does not act like a “know it all”
 Normalizing:
seeing psychotic problems
as just more extreme versions of everyday
ones
 Focusing on the story of how the current
problem came about and was perpetuated
Hearing a voice
Sense of threat
and negative
mood leads to
hypervigilance
for more input
from voices
(listening harder
for them)
Interpret voice
as a threat
Perception of
threat increases
negative mood
Three ways of working with an
apparently delusional belief:
 1.
Explore the person’s story prior to
developing the belief
 2. Explore the evidence for and against
the belief
 3. Help the person look at how they might
better succeed in life even while they keep
the belief
Hallucinations
 Cognitive
therapists see these as just our
own thoughts or representations of
something in the world, temporarily
mistaken for something coming in directly
from the external world
 Cognitive therapists don’t try to get rid of
these, just change the way we understand
them
Cognitive
Therapy for
Psychosis
Presenter: Ron Unger LCSW
Advantages of cognitive therapy for
psychosis
 It
focuses on simple patterns which, if not
interrupted, can generate complex
problems
 It is respectful and collaborative

 It
At least when done well
has very specific ideas about what
people can do to resolve problems with
psychotic experiences
Definition of “Psychosis”
 “A severe
mental disorder, with or without
organic damage, characterized by
derangement of personality and loss of
contact with reality and causing
deterioration of normal social functioning.”

Definition found in American Heritage Stedman’s Medical
Dictionary
Social Support and Dialogue

Easily available to those who are “normal”

More difficult to find for those who are
“neurotic”

Very difficult or impossible to find for those
who are “psychotic”

The more you need it, the less available it
is
Psychosis
contributes
to often
extreme
social
isolation
Isolation
increases
likelihood
of
psychotic
symptoms
Dialogue and Rationality
 Rationality
emerges out of dialogue
 Not by suppressing "irrational"
views
 Instead, it is engaging one view in
dialogue with another view that
creates “rationality”
My feelings
and emotions
tell me what is
real: if I'm
feeling down
then I'm doing
terrible, if I feel
scared, then I’m
in danger, etc.
My feelings and
emotions give
me suggestions
about what may
be real.
I decide whether
they are accurate
or not. If they are
accurate, I act on
them, if not, I just
accept them and
let them go.
My feelings
and emotions
are my
enemy: I need
to block them
out (or drug
them away)
My voices tell
me what is
real: if they tell
me I’m doing
terrible then I
am, if they tell
me I’m in
danger then I
am, etc.
My voices give
me suggestions
about what may
be real.
I decide whether
they are accurate
or not. If they are
accurate, I act on
them, if not, I just
accept them and
let them go.
My voices are
my enemy: I
need to block
them out (or
drug
them away)
One thing that can disrupt internal
dialogue: Trauma

When arousal is too great, parts of the mind that
generate internal dialogue evaluating danger
can shut down



Which can be good in extreme situation
Problem is when it doesn’t start up again afterward
When experience seems too much to face, long
term problems can result


Not just PTSD
A host of other problems, including “psychotic
symptoms”
What is most essential:
 Establishing
and maintaining a good
relationship is more important than any
other therapeutic activity

So if anything you are doing interferes with
the relationship, stop it!
• at least until you find a way to do it that does not
interfere with the relationship
General Practices
 Start
with befriending, social conversation,
and relevant self-disclosure
 Avoid jargon but don’t talk down to the
person
 Suspend your disbelief
 Collaborative Empiricism
 Walk a middle road between confrontation
and collusion
Normalizing:
 Interpreting
psychotic experiences as an
understandable reaction to events or
combinations of events


This reduces the panic and emotional arousal
that often leads to more symptoms
Normalizing means looking at experiences as
existing on a continuum, not divided into
categories such as sane and insane
“Psychotic”
story: I have
to believe this
story for
important
emotional
reasons, even if
it gets me into
serious trouble
Evolving Human
Story: As I
reflect on things, I
can develop
stories that meet
my emotional
needs while also
allowing me to
relate well to
others
Psychiatric
story: my
beliefs and
experiences
are caused by
my disease, for
example,
schizophrenia
From: The Case Study Guide to Cognitive Behaviour Therapy of Psychosis, Edited by David Kingdon & Douglas Turkington
From: Cognitive Therapy for Psychosis: A Formulation-Based Approach, by Morrison et al
A Developmental Formulation
Negative identity defined by others, felt crushed
Learned how to make up own identity, own world view (drugs amplified this)
Often overdid it, getting grandiose or nonsensical, rejecting reason entirely
Others couldn’t understand, often had poor relationships
But
Found some others who could understand & appreciate self,
Felt inspired to make more sense to others, resulting in more coherent identity
Three ways of working with
delusions:






1. Explore the developmental background out
of which the delusion developed, in other words,
work on the formulation.
2. Explore the delusion itself by
exploring the evidence for and against it
developing self-esteem preserving
alternatives
testing out beliefs
3. Help the person expand engagement with the
world and with other people, which reduces
preoccupation with the delusion
From: Models of Madness: Psychological, Social and Biological Approaches to Schizophrenia, Edited by Read, Mosher & Bentall
Simplest Conceptualization of
Hallucinations:
Hallucinations are the person's own
thoughts,
in words, images, or whatever,
which seem to be,
or are interpreted to be,
coming from outside the person's own
mind.
Hypervigilant:
Afraid of not seeing
a threat that may be
present
Blocks out or
looks away
from signs of
danger
Anxious, aroused,
perceiving a threat
in the absence of
good evidence
Interprets self as overreacting: afraid of going
mad or appearing mad
Confusion caused by co-existence of hypervigilance and blocking
perceptions
The goal of cognitive work with
psychosis is not to eliminate
voices or hallucinations,
anymore than the goal of
cognitive work with panic is to
eliminate the body sensations
that are often misinterpreted as
something else
My emotions
(or voices) tell
me what is
real: if they tell
me I’m doing
terrible then I
am, if they tell
me I’m in
danger then I
am, etc.
My emotions (or
voices) give me
suggestions
about what may
be real.
I decide whether
they are accurate
or not. If they are
accurate, I act on
them, if not, I just
accept them and
let them go.
My emotions
(or voices) are
my enemy: I
need to block
them out (or
drug
them away)
Three levels of belief about
voices:
1., Beliefs about content
2., Beliefs about power
3., Beliefs about identity
How to change beliefs about
voices:
 Beliefs

Use steps similar to those used when working
with “automatic thoughts”
 Beliefs

about power
Help the person develop better coping tools
and so increase personal power in relation to
the voices
 Beliefs

about content
about identity
Explore interpretations, and evidence for
interpretations, that are less distressing
Beliefs about the identity of voices
 The
most helpful beliefs are those that
give the person a sense of power in
relation to the voice
 It might be important to explore the
advantages and disadvantages of certain
beliefs, not just the evidence for and
against
 Don’t insist on a scientific understanding

As long as a person gains a sense of power in
relation to the voice, he or she may be fine
Other factors addressed by
cognitive therapy for psychosis
 The
emotional arousal that underlies many
of the more obvious “psychotic symptoms”
 The sense of defeat that often underlies
“negative symptoms”
 Social anxiety and social withdrawal
 Apparently disorganized thinking
 Paranoia, which is seen as on a spectrum
with everyday anxiety & trust issues
Summary:
Think of psychotic states as having roots in normal human
concerns
Join with the client, around exploring what might relieve their
distress
Suspend your beliefs, instead joining in a collaborative
empirical exploration with the client, drawing out the client's
own rational process.
Work out with the client an alternative way of making sense
of his or her experience, with consequences that are less
distressing.
And do this while avoiding "cultural imperialism:" in other
words, be open to the idea that your proposed alternatives,
like the clients own original formulation, may be only partially
correct or helpful.