Cognitive Therapy for Psychosis Presenter: Ron Unger LCSW

The Essential idea of Cognitive- Behavioral 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” 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 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”

Cognitive therapy for psychosis  Is a systematic approach  Is well researched At least 23 randomized studies At least 23 randomized studies Is considered an “evidence based practice” 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 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” 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

Sense of threat and negative mood leads to hypervigilance for more input from voices (listening harder for them) Interpret voice as a threat Hearing a voice 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 At least when done well At least when done well  It 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 Not by suppressing "irrational" views Instead, it is engaging one view in dialogue with another view that creates “rationality” 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 are my enemy: I need to block them out (or drug them away) 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 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 are my enemy: I need to block them out (or drug them away) 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.

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 Which can be good in extreme situation Problem is when it doesn’t start up again afterward 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 Not just PTSD A host of other problems, including “psychotic symptoms” 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! 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 relationshipat 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 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 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 Psychiatric story: my beliefs and experiences are caused by my disease, for example, schizophrenia 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

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 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, Hallucinations are the person's own thoughts, in words, images, or whatever, in words, images, or whatever, which seem to be, which seem to be, or are interpreted to be, coming from outside the person's own mind.

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) are my enemy: I need to block them out (or drug them away) 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.

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 about content Use steps similar to those used when working with “automatic thoughts” 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 Help the person develop better coping tools and so increase personal power in relation to the voices  Beliefs about identity Explore interpretations, and evidence for interpretations, that are less distressing 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 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.