CBT with positive symptoms

Positive responders to CBT Those who respond best are : Anxious & distressed by symptoms Have some insight, even if fluctuating Also respond best to medication - symptoms remit without CBT, but : - CBT offers understanding & ‘integration’, reduces relapse, improves social functioning (Garety et al, 1997)

Assessment & engagement 2 elements: Understanding of why person believes what they believe Providing credible alternatives - person previously dismissed circumstances leading to psychotic episode as irrelevant - Explanations solely based on biological factors lack credibility - Explore their understanding - Explore effects on sleep, anxiety, depression - Develop collaboration

Building a rapport Dependent on personality Difficult to work as ‘therapist’ Offer broader discussion, ie housing etc Clarify THEIR agenda, what is important to them Use alternative team members for specific concerns Persistence : but care not to harass, be coercive, deny choice or be probing & cajoling Warmth & humour can be misinterpreted – watch for persons reaction Laughter & silence should be carefully handled initially Establish & use a common language

Issues that may influence progress or approach Vulnerability :Intermediary personality factors ie, perfectionism, paranoid character Abnormalities to brain structure or function, indicated by delay in developmental milestones, solitary play (Jones et al,1994) Infection Drugs Life events Could be a combination

Timing Consider frequency & thought processes Don’t try to do too much in one session Consider length of time for rumination & building delusional formulation. More frequent appointments may be needed to provide explanations/ offer alternative Leave enough time between sessions to allow for reflection & discourage sense of ‘harassment’

Duration of sessions Should be sensitive to SU rather than professionals practice/routine Allow time for explanations Consider length of attention span May be better shorter but more frequent sessions Need to allow for thought processes

Approaches Aim for sessions to be positive, enjoyable/ helpful Ensure understanding Let SU take the lead Explore their models first Don’t refute their explanations Offer alternative explanations : Give timely information, leaving more information for further visits promotes future engagement Use vulnerability/ stress model for explanation Normalise but don’t minimise

Approach (cont.) Keep open mind Don’t pressure – will tell you when they are ready, may fear focussing may bring on symptoms Review stress management & coping skills Readjust expectations- aim for convalescence, ‘feeling better’, small steps

Explaining psychosis using ‘normalising’ rationale Can help ‘integrate’ experience May vary in how much the person wants an explanation (‘integrators’ seek understanding) Need to consider engagement Need to be guided by the individual

Vulnerability model Draws together components : predisposition, precipitation, perpetuation Explains that problems can be brought about by stressful circumstances if they are vulnerable Multi-dimensional cause – management multi- dimensional Contrasts to theories that over-simplify a complex disorder, ie biological

Delusions / beliefs Collaborative assessment of supporting & disconfirming evidence is essential ‘stalemates’ frequent where alternatives are not forthcoming or accepted – behavioural approaches: diversion & reducing time for rumination, focus on engagement. ‘agree to disagree’ Explore alternatives for specific symptoms Anxiety = giddiness = ‘controlling mind’ Explain autonomic thoughts Because you think something doesn’t mean: ‘it is true’ ‘you are evil’ ‘you have to act on it’

‘ Do you think I’m ill?’ Therapist :‘ beliefs may not be as they seem/ you describe them, but could be stress or illness related’ May be seized upon negatively - ‘You are like all the others’ Solution: Move towards self discovery through their providing evidence, checking out, draw to own conclusions Therapist : ‘what do you think?’ ‘how important is what people think to you?’

Approaches to delusional beliefs ‘I’m not yet convinced you are ……….. If others did believe you what would that mean?’ Explore additional material/ feelings as may assist identifying key problems Straight forward discussion of evidence can lead to increased delusional material to support belief Where delusions are grandiose, issues of self esteem are common Consider loss of delusion/ belief, ie, what it mean not to be ………… in reality - explore further, becomes a focus for therapy, possible relationship difficulties

Challenges Those who are isolated Those who have cut off from social interaction Those who have developed a resistance to change Those who have severe concurrent affective symptoms Solutions May need to wait response from medication before commencing CBT Can listen, allow for expression Behavioural approaches Work with family

Isolation Assess reasons for & work with isolation - social phobia - Delusions of reference - Fear of exacerbation of symptoms - Discuss avoidance Explore impact of isolation - possible ostracising by others where discussion is uncontained - social withdrawal or relationship difficulties Consider containment in social environments Allow for discussion in planned sessions

Thought interference Distressing – feel they have no privacy or freedom from interference Commonly explained/ expressed as ‘telepathy’ Reference may impact on activity/ isolation Distracting during therapy/ sessions

Techniques Use of different mediums, ie art, writing Reality testing Socratic questioning -enquiry without making assumptions - conversational rather than staccato Guided discovery Psycho-education – timely, sensitive information Clarity on explanations Homework – enhances collaboration, involvement, control Normalising symptoms -reduces fear & confusion

Beliefs about hallucinations : - Reattribute as thoughts - Eliminate possibility of drugs, deprivation states can cause ‘voices’ - Discuss similarities to dreaming - Explore & work with trauma

Useful phrases ‘I need to know more before I can agree’ Where SU responds to smile/ non verbal cue by becoming guarded: ‘Did I do something to upset you?’ ‘Did my smiling at what you said concern you?’ ‘I’m feeling ……….., is that how you feel?’ ‘At the moment I’m not sure but I would like to listen to know more’ ‘I don’t understand, would you try to explain about…/ what you are thinking…’ DON’T REFUTE Eg: ‘ But if this was the case,……….’ ‘How could this be so?’