1. Cognitive Behaviour Therapy for Psychosis In Practice David Kingdon University of Southampton Southampton, UK (dgk@soton.ac.uk)

2. Therapeutic process of CBT Information on current beliefs and how they were arrived at is assembled into a formulation ENGAGEMENT ASSESSMENT FORMULATION There is a strong focus on individualised engagement of the patient building on good psychiatric practice Agendas are less explicit, feelings are elicited with great care and homework is used sparingly Assessment is based on clinical practice Emphasis is placed on understanding the first episode in detail, which may hold the key to current beliefs

3. Current problems A formulation for making sense of patients’ beliefs and experiences What happened before? What started it? What’s kept it going? What can help stop it? Thoughts PhysicalSocial FeelingsBehaviour Underlying concerns

4. Overall aim of CBT for schizophrenia Work with delusions Work with hallucinations Work with negative symptoms AIM To reduce distress and disability

5. Work with delusions

6. Delusions trace beginnings of delusion build a picture of preceding period –identify significant life events & circumstances –identify relevant perceptions (e.g. tingling, fuzzy feeling) & thoughts (e.g. suicidal, violent) explore content of delusion: –evidence for & then against the delusion

7. Delusions elicit alternatives: –‘can you think of any other possibilities?’ –‘if someone said that to you, how would you respond?’ exploration/investigation of beliefs –follow up any theoretical proposition,  e.g. that they are being influenced by satellites – suggest gathering relevant information about satellites ‘reality testing’ is useful in assessment & engagement & may also begin to sew doubts

8. Resistant delusions if going round in circles –‘Agree to differ’ –review key issues & concerns that have emerged: e.g. ‘I don’t want to end up like my mother’, ‘I haven’t got a girlfriend’, ‘I’m useless’ –it may be possible now to work directly with these –behaviour often changes first ….. Other psychological techniques may be helpful, e.g. work on worry & moving on

9. Work with voices

10. VOICES Are they distressing? –If not, is there sufficient reason for therapeutic intervention?  e.g. effect on behaviour - where it leads to social ostracization or interference with functioning Clarify experience: –Are they like ‘someone speaking to you like I’m doing now’..or ‘maybe whispering or shouting’

11. REATTRIBUTION OF VOICES Explore the individual focus of the experience –‘Can anybody else hear what is said?’ ‘Not parents, friends, etc?’ Discover the patients beliefs about the voices’ origin: –‘Why do you think others can’t hear them?’ Debate these beliefs: –Use techniques for delusions, if appropriate, e.g. because the CIA have a machine that can do this or God can speak to people in this way –Explore doubts: ‘I’m not sure how they come..’

12. REATTRIBUTION OF VOICES Look for explanations: –‘It may be schizophrenia’ (‘but I wish the neighbours would stop it..’) –Use ‘normalizing’ alternatives:  deprivation states & other stressful circumstances: eg bereavement, taken hostage, PTSD; dreaming/nightmares Aim for acceptance of the possibility that the voices might be to do with themselves - their own thoughts

13. CONTENT OF VOICES Explore what they say: –Weigh up evidence to support and refute what is said: e.g. ‘you’re useless..’ –Explore any relevance to previous traumatic events or drug-related experiences Explore beliefs about them: –‘I have to do what they say’ –‘They know everything’

14. Coping strategies Behavioral control –e.g. relaxation, warm bath, go for walk Socialisation –e.g. friends, day centres Medical care –e.g.. control of medication, call care worker Symptomatic behaviour –e.g. get drunk or drugged, punch policeman Cognitive control –e.g.. TV, music, crosswords,

15. Work with negative symptoms

16. NEGATIVE SYMPTOMS optimise medication regimes manage positive symptoms –especially ideas of reference, voices & thought broadcasting which can be reactivated as social and other activity increases manage any depression, anxiety & agoraphobia/social phobia

17. NEGATIVE SYMPTOMS Consider the protective function of the symptoms, e.g.: –avoidance of over-stimulation –protection from relapse of positive symptoms Assess how much pressure the patient and family perceive: –Reduce pressure where possible –Review immediate expectations –Use realistic long-term planning, e.g. ‘take a year off then reconsider going to college when you feel ready’ –Reduce level of activity if it is causing distress

18. OVERALL AIM To reduce –Distress & –Disability To promote –Empowerment & –Recovery CBT work with symptoms, e.g. delusions, hallucinations & negative symptoms, can be a means to those ends

19. American Psychiatric Association Press, 2008 CUP, 2009