1. Cognitive Behaviour Therapy for Psychosis In Practice
David Kingdon
University of Southampton
Southampton, UK

2. Therapeutic process of CBT
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
ENGAGEMENT
ASSESSMENT
Assessment is based on clinical practice
Emphasis is placed on understanding the first episode in detail, which may hold the key to current beliefs
FORMULATION
Information on current beliefs and how they were arrived at is assembled into a formulation

3. 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?
Current problems
Thoughts
Physical
Social
Feelings
Behaviour
Underlying concerns

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

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: exploration/investigation of beliefs
‘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? Clarify experience:
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: Explore beliefs about them:
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 Socialisation Medical care
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,
Develop a dialogue

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 To promote Empowerment Distress & & Disability
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