psychological therapy for psychosis

Question 1

what is psychosis

Answer 1

loss of contact with reality

Question 2

what psychiatric disorders does psychosis describe

Answer 2

Term used to describe the characterisic complaints of several psychiatric
disorders, most notably diagnoses in the schizophrenia-spectrum
(schizophrenia, schizo-afecive disorder, delusional disorder etc)

Question 3

what does psychosis involve

Answer 3

It involves clusters of “symptoms” including positive symptoms (hallucinaions,
delusions etc) and negaive symptoms (flat affect, avolition etc)

Question 4

what are positive symptoms

Answer 4

Present in people who have psychosis but are assumed to be absent in people who do not have psychosis

Question 5

what are negative symptoms

Answer 5

Negative symptoms are experiences that are absent or reduced in people who have psychosis and are assumed to be present in those who do not have psychosis

Question 6

are the symptoms in psychosis common in the general population

Answer 6

In the general populaion these symptoms are not rare and are generally
unproblematic, but in some individuals they can lead to considerable distress
and reduction in functioning

Quite common - don’t need any mental health support
Minority of individuals in which these experiences can be come highly distressing and debilitating and can impact the functioning and therefore might benefit from some form of additional support

Question 7

what are the factors involved in development and maintenance of psychosis

Answer 7

Biological but also psychosocial factors are involved – despite this service
users have mostly receive only biological treatments (anipsychotics)

Question 8

when did psychological therapies for psychosis become accepted

Answer 8

Psychological therapies for psychosis did not become widely
invesigated or accepted as potenially useful treatments unil the
1990s

Question 9

why was there a delay in developing talking treatments for psychosis

Answer 9

• Psychosis was seen as fundamentally diferent from neurosis (presentations like anxiety and depressions seen as more amenable to psychological interventions)
• Symptoms not seen as understandable in psychological terms (e.g. Jaspers)
• Lack of therapeuic opimism in the treatment of “schizophrenia”.
– Poor results from early trials of psychotherapy.
early days primarily focused on psychodynamic or psychoanalytic approaches
– neuroleptics seen as only viable treatment option

Outdated term for what we would call today antipsychotic medication were seen as the only viable option for supporting people with this psychiatric diagnosis of schizophrenia and related psychotic disorders

Question 10

name the 5 psychological therapies for psychosis

Answer 10

• Rogerian Counselling
• Psychoanalyic therapies
• Cogniive Behaviour Therapy
• Family therapy
• Intervenions to reduce substance misuse

Question 11

why is cbt important in treating psychosis

Answer 11

evaluated the most
research trials
clinical application

Question 12

what is CBT

see slide 9

Answer 12

activating event (internal or external)
thoughts (negaive automaic thoughts, thought distorions, appraisals etc)
behaviours
feelings/emotions

Question 13

what is an activating event (internal and external)

Answer 13

Events can be both external so actual experiences that they will encounter ver the course of a daily life or also internal experiences so e.g. particular memory or perceptual experience

Question 14

what is CBT for psychosis

Answer 14

Cogniive Behaviour for Psychosis (CBTp) is the applicaion (and adaptaion) of
the same basic principles to understand the distress and impairment caused
by psychoic experiences

Question 15

how does NICE define CBTp

Answer 15

The National Insitute of for Health and Care Excellence (NICE, 2014) defines
CBTp as a psychological intervenion where service users:

o Establish links between, thoughts, beliefs, percepions and feelings in
relation to their current or past symptoms and/or functioning

o Re-evaluate their beliefs, percepions and reasoning relaing to target
symptoms

o CBTp should involve development alternaive ways of coping with the
target symptoms, and/or reducion of distress, and/or improvement of
funcioning.

Question 16

what is NICE

Answer 16

The Naional Insitute of for Health and Care Excellence (NICE, 2014)

Question 17

what are the basic CBTp strategies

Answer 17

• Formulating (making sense)
• Normalising psychosis
• Improving coping
• Strategies to change unhelpful thoughts, beliefs and appraisals
- That they have in relation to their difficulties and that perhaps are involved in the maintenance of their difficulties in keeping the problem over time

Question 18

what is formulating?

Answer 18

Typically when an early goal for therapy is agreed in the early session of the intervention so for example which specific problem the client would like to improve and the therapist will carry out a detailed assessment to identify thoughts feelings behaviours etc that are linked to the presenting difficulties that the clients wants to change then the therapist will work gradually with the client to help them understand how these factors thoughts feelings behaviours interact with each other and maintain these problems in the present, ultimately this enables to create an element of a shared understanding of how the problem is developed and how to resolve or improve it

Question 19

how the therapist formulates psychotic experiences

Answer 19

After appropriate goals for therapy are identified (e.g. which problem/symptom to target), the therapist carries out an assessment to:

o Identify thoughts, feelings behaviours etc linked to the problem/symptom targeted
o Help the client to see how these interact to maintain the problem in the present
o Create a shared understanding of how the problem developed and what could be done to resolve it

It involves enabling the clients to understand in more detail how the difficulties came about and how they are maintained in the present using the general principle of cognitive behavioural theories for understanding that specific difficulties

Question 20

what do therapists use in CBT to formulte difficulties

Answer 20

Often in CBT, therapists use well-established models to formulate difficulties (“templates”)

Question 21

cognitive model of hallucinations state hallucinations are

Answer 21

In common with other cognitive models of mental health difficulties this model assumes that auditory hallucinations are not distressing and problematic in themselves the distress and impairment caused by these experiences is driven by how the person makes sense of these experiences

Question 22

what does the cognitive model of hallucinations state triggers are

Answer 22

internal or external e.g. stress, sleep deprivation, isolation

Question 23

cognitive model of hallucinations stages

Answer 23

triggers - auditory hallucinations - safety behaviours - misinterpretation of hallucinatory experience - mood and physiology

Question 24

why do hallucinations cause distress according to the cognitive model of hallucinations

Answer 24

If a person interprets or misinterprets the hallucinatory experience in a catastrophic negative way they might experience negative arousal negative emotions nad distress which in truth might have an impact on the presence of hallucinations in themselves so the intense arousal of these interpretations might actually make the presence of the auditory hallucination more severe and frequent

Depending on how people interpret these hallucinatory experiences people will try to employ different safety behaviours so way of coping with these unwanted experiences some of which might actually paradoxically increase tree future severity or presence of hallucinatory experiences

negative appraisal of the experience

Question 25

what will CBT do to help negative appraisals

Answer 25

change the appraisal so that the meaning making the person has employed to make sense of their voice is better
better ways of coping

Question 26

when does normalisation happen

Answer 26

normally happens towards the early stages

Question 27

what is formulating in CBTp

Answer 27

making sene of psychotic experiences

Question 28

why do we need to normalise psychosis as part of CBTp

Answer 28

The rational for normalisation of psychosis is that essentially people when they come to therapy not only are reporting distressing voices unusual beliefs but often come with the whole baggage of notion of what it means to be psychotic schizophrenic and the dangers associated with that
People will often have beliefs that their brain is defective and will never get better and things will only get worse etc

Question 29

what does normalising psychosis mean?

Answer 29

• Challenging the (internalised) stigma of psychosis
• Correcting common misconceptions about psychosis, its causes and its consequences
• Provision of more accurate information
• Promotion of more balanced views about psychosis

Question 30

are people with psychosis dangerous

Answer 30

There is no evidence that people with psychosis are more dangerous or violent than the general populaion. Violence in psychosis is explained mostly by other factors (substance misuse, pre-exising history of violence, criminal involvement
etc) (acute confusion etc.)
• People are more likely to be withdrawn or preoccupied with their own problems
• People with psychosis are much more likely to be the vicim of violence rather than the perpetrator (e.g. Maniglio 2009)

Question 31

is psychosis for life?

Answer 31

• Psychosis is not necessarily for ever.
• Many people have a single episode that never occurs again (about 30%).
• Some people experience more than one episode even ater long periods of being symptom-free (about 30%).
• A minority of people have persistent ongoing symptoms (< 25%).

Recovery and remission from psychotic experiences is the norm rather than the exception

Question 32

are people with psychosis unable to work?

Answer 32

• There might be imes when a person’s distress is such that it interferes with their
ability to funcion but this is not necessarily so.
• Many people who have experienced or currently experience symptoms of
psychosis are able to work, have relationships and manage to function in their life.

Question 33

does psychosis always cause distress and do people always need treatment?

Answer 33

• Many people experience unusual beliefs or hear voices, but are not distressed by
these experiences (e.g. van Os et al., 2000)
• Many people make sense of their experiences in a way they can ind helpful
(e.g. psychic experiences/ telepathy, reincarnaion, shamanism etc.).
• In some cultures, psychoic symptoms are viewed posiively (e.g. Al-Issa, 1997).

May find ways of interpretations experiences in a helpful way so e.g. reframe as manifestation of some kind of ability they might have such as having psychic experiences for example

Normalisation of psychosis - expose people to this different kind of understanding of psychotic experiences
Encourage understanding that the distress they experiences is related to the way theyre making sense of the experience - different ways of framing this experience can be more or less distressing for people

Question 34

what can psychotic experience be brought about by?

Answer 34

Psychoic experiences can be brought about by many experiences such as:
– Lack of sleep
– Sensory deprivaion
– Substances or aciviies creaing altered states of consciousness
– Stressful events (hostage situations,combat stress and other life threatening situations etc)
– Bereavement
– Trauma (bullying, abuse, violence in home, run away from home, placed in care as achild etc)
– brain disease

Question 35

what is improving coping

Answer 35

Important element of CBT for psychosis is the provision of additional and helpful ways for coping with psychotic experience

Question 36

what do coping strategy enhancements consist of?

Answer 36

• The aim is to (1) increase the repertoire of coping strategies the client can use when facing distressing symptoms, (2) provide some respite, (3) encourage a greater sense of control

o Reviewing the strategies the client already uses to cope with psychoic experiences, how often/when they are used and how effecive they are

o Encourage the client to experiment with new coping strategies

Question 37

name some of the coping strategies based on our understanding of symptoms of psychosis (e.g. relationship between inner speech and auditory verbal hallucinaions)

Answer 37

-humming
-reading
-singing
-reduce subvocalisation (filling our mouth with water)
coping starategies that interfere with the generation of inner speech has been shown to be effective in reducing the intensity of voices)

Question 38

what are the coping strategies based on responding diferently to symptoms

Answer 38

o Acing asserively / Dismiss the voice
o “Making an appointment “ with the voices
o Respond raionally to the voice content

Question 39

what are the coping strategies to reduce arousal and distress

Answer 39

o Listen to soothing music
o Mindfulness meditaion
o Relaxaion exercises
o Use posiive imagery / self-statements etc…

Question 40

how to challenge unhelpful beliefs/appraisals of psychotic experiences

Answer 40

Use Socraic quesioning in session
Ask paricipants to keep a log of recent voice hearing experiences
Evidence / counterevidence analysis
Behavioral experiment

Question 41

what is a behavioural experiement

Answer 41

Ask client to test out maladaptive belief they have - stop all safety behaviours and see if they really lose control - following a risk assessment. - vast majority of circumstances people just have belief that might happen and the chance they carry out violent behaviour because of their psychotic experiences is actually minimal they are distressed because they are concerned about it

Question 42

is cbt for psychosis effective - randomised controlled trials

Answer 42

Over 50 RCTs have examined the ecacy of CBT in people with psychosis, with posiive indings across most “stages” of psychosis:

First episode psychosis / early psychosis (e.g. Tarrier et al. 2004)
Acute psychosis (e.g. Lewis et al., 2002; Garety et al., 2008)
People at risk of relapse (e.g. Gumley et al., 2003)
Treatment resistant psychosis (e.g. Durham et al., 2003; Valmaggia et al., 2005; Turkington et al., 2008)
Groups (Chadwick et al., 2000; Johns et al, 2002)

Question 43

is cbt effective - meta-analyses

Answer 43

These meta-analyses have shown that CBT can improve psychoic symptoms, especially in the case of posiive symptoms

Question 44

can CBTp be effective without Neuroleptics

Answer 44

CBTp can be efecive on its own, even in individuals that are not taking anipsychoic medicaion

Question 45

what does NICE reccomend in terms of CBT for treating psychosis

Answer 45

NICE (2014) recommends that CBT should be ofered as a first line treatment across the coninuum of psychosis
• People at clinical high risk (prodrome)
• First episode psychosis
• “Chronic psychosis” to promote recovery

Question 46

what does NICE reccomend in relation to trauma

Answer 46

NICE also recommends that all people with psychosis should be assessed for trauma and post-traumaic stressed and offered trauma-focused psychological therapies (including CBT) when appropriate (BUT recommended more research into their safety and efficacy in this specific populaion)

Strong link between trauma and life adversities and the risk of developing psychosis - NICE recognise this - CBT could be applied - emotional and psychological consequences or trauma