Cognitive Therapy for Psychosis

Presenter: Ron Unger LCSW

The Essential idea of Cognitive-The Essential idea of Cognitive-Behavioral Therapy:Behavioral Therapy:

If you learn to think and act differently, If you learn to think and act differently, then your mental and/or emotional then your mental and/or emotional problems can disappearproblems can disappear

You are the one who is responsible for You are the one who is responsible for changing thoughts and behaviors, though changing thoughts and behaviors, though others may help you figure out how to do itothers may help you figure out how to do it

Language from official US Language from official US government website:government website:

““What causes schizophrenia?What causes schizophrenia? ““Schizophrenia is nobody’s fault. This Schizophrenia is nobody’s fault. This

means that you did not cause the disorder, means that you did not cause the disorder, and neither did your family members or and neither did your family members or anyone else. Scientists believe that the anyone else. Scientists believe that the symptoms of schizophrenia are caused by symptoms of schizophrenia are caused by a chemical imbalance in the brain.”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 psychosisCognitive therapy for psychosis

Is a systematic approach Is a systematic approach Is well researchedIs well researched

At least 23 randomized studiesAt least 23 randomized studies Is considered an “evidence based practice”Is considered an “evidence based practice”

Being systematic and “evidence based” Being systematic and “evidence based” provides some weight when attempting to provides some weight when attempting to push back against the “medical model”push back against the “medical model”

Cognitive Therapy and MedicationsCognitive Therapy and Medications

The evidence base is mostly with clients who The evidence base is mostly with clients who also took medicationsalso took medications Cognitive therapy worked to reduce the symptoms the Cognitive therapy worked to reduce the symptoms the

medication did not controlmedication did not control As a result of cognitive therapy, clients are often As a result of cognitive therapy, clients are often

able to use less medicationable to use less medication Case study reports show cognitive therapy is Case study reports show cognitive therapy is

often helpful with clients who refuse often helpful with clients who refuse medications.medications.

One research study showed cognitive therapy One research study showed cognitive therapy alone was effective in reducing risk for people alone was effective in reducing risk for people just starting to experience psychotic symptomsjust starting to experience psychotic symptoms

How does it work?How does it work?

A collaborative, respectful relationship is A collaborative, respectful relationship is keykey Therapist does not act like a “know it all”Therapist does not act like a “know it all”

Normalizing: seeing psychotic problems Normalizing: seeing psychotic problems as just more extreme versions of everyday as just more extreme versions of everyday onesones

Focusing on the story of how the current Focusing on the story of how the current problem came about and was perpetuatedproblem 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

HallucinationsHallucinations

Cognitive therapists see these as just our Cognitive therapists see these as just our own thoughts or representations of own thoughts or representations of something in the world, temporarily something in the world, temporarily mistaken for something coming in directly mistaken for something coming in directly from the external worldfrom the external world

Cognitive therapists don’t try to get rid of Cognitive therapists don’t try to get rid of these, just change the way we understand these, just change the way we understand themthem

Cognitive Therapy for Psychosis

Presenter: Ron Unger LCSW

Advantages of cognitive therapy for Advantages of cognitive therapy for psychosispsychosis

It focuses on simple patterns which, if not It focuses on simple patterns which, if not interrupted, can generate complex interrupted, can generate complex problemsproblems

It is respectful and collaborativeIt is respectful and collaborative At least when done wellAt least when done well

It has very specific ideas about what It has very specific ideas about what people can do to resolve problems with people can do to resolve problems with psychotic experiencespsychotic experiences

Definition of “Psychosis”Definition of “Psychosis”

““A severe mental disorder, with or without A severe mental disorder, with or without organic damage, characterized by organic damage, characterized by derangement of personality and loss of derangement of personality and loss of contact with reality and causing contact with reality and causing deterioration of normal social functioning.” deterioration of normal social functioning.”

Definition found in American Heritage Stedman’s Medical Definition found in American Heritage Stedman’s Medical DictionaryDictionary

Social Support and DialogueSocial Support and Dialogue

Easily available to those who are “normal”Easily available to those who are “normal”

More difficult to find for those who are More difficult to find for those who are “neurotic” “neurotic”

Very difficult or impossible to find for those Very difficult or impossible to find for those who are “psychotic”who are “psychotic”

The more you need it, the less available it The more you need it, the less available it isis

Psychosis contributes to often extreme social isolation

Isolation increases likelihood of psychotic symptoms

Dialogue and RationalityDialogue and Rationality

Rationality emerges out of dialogueRationality emerges out of dialogue Not by suppressing "irrational" Not by suppressing "irrational"

viewsviews Instead, it is engaging one view in Instead, it is engaging one view in

dialogue with another view that dialogue with another view that creates “rationality”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 drugthem 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 drugthem 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 One thing that can disrupt internal dialogue: Traumadialogue: Trauma

When arousal is too great, parts of the mind that When arousal is too great, parts of the mind that generate internal dialogue evaluating danger generate internal dialogue evaluating danger can shut downcan shut down Which can be good in extreme situationWhich can be good in extreme situation Problem is when it doesn’t start up again afterwardProblem is when it doesn’t start up again afterward

When experience seems too much to face, long When experience seems too much to face, long term problems can resultterm problems can result Not just PTSDNot just PTSD A host of other problems, including “psychotic A host of other problems, including “psychotic

symptoms”symptoms”

What is most essential:What is most essential:

Establishing and maintaining a good Establishing and maintaining a good relationship is more important than any relationship is more important than any other therapeutic activityother therapeutic activity So if anything you are doing interferes with So if anything you are doing interferes with

the relationship, stop it!the relationship, stop it!• at least until you find a way to do it that does not at least until you find a way to do it that does not

interfere with the relationshipinterfere with the relationship

General PracticesGeneral Practices

Start with befriending, social conversation, Start with befriending, social conversation, and relevant self-disclosureand relevant self-disclosure

Avoid jargon but don’t talk down to the Avoid jargon but don’t talk down to the personperson

Suspend your disbeliefSuspend your disbelief Collaborative EmpiricismCollaborative Empiricism Walk a middle road between confrontation Walk a middle road between confrontation

and collusionand collusion

Normalizing:Normalizing:

Interpreting psychotic experiences as an Interpreting psychotic experiences as an understandable reaction to events or understandable reaction to events or combinations of events combinations of events This reduces the panic and emotional arousal This reduces the panic and emotional arousal

that often leads to more symptomsthat often leads to more symptoms Normalizing means looking at experiences as Normalizing means looking at experiences as

existing on a continuum, not divided into existing on a continuum, not divided into categories such as sane and insanecategories 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 FormulationA Developmental FormulationNegative identity defined by others, felt crushedNegative identity defined by others, felt crushed

Learned how to make up own identity, own world view (drugs amplified this)Learned how to make up own identity, own world view (drugs amplified this)

Often overdid it, getting grandiose or nonsensical, rejecting reason entirelyOften overdid it, getting grandiose or nonsensical, rejecting reason entirely

Others couldn’t understand, often had poor relationshipsOthers couldn’t understand, often had poor relationships

ButBut

Found some others who could understand & appreciate self,Found some others who could understand & appreciate self,

Felt inspired to make more sense to others, resulting in more coherent identityFelt 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 Simplest Conceptualization of Hallucinations:Hallucinations:

Hallucinations are the person's own Hallucinations are the person's own thoughts, thoughts,

in words, images, or whatever, in words, images, or whatever,

which seem to be, which seem to be,

or are interpreted to be, or are interpreted to be,

coming from outside the person's own coming from outside the person's own mind. mind.

Confusion caused by co-existence of hypervigilance and blocking perceptions

Hypervigilant: Afraid of not seeing a threat that may be present

Anxious, aroused, perceiving a threat in the absence of good evidence

Interprets self as over-reacting: afraid of going mad or appearing mad

Blocks out or looks away from signs of danger

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 drugthem 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 How to change beliefs about voices:voices:

Beliefs about contentBeliefs about content Use steps similar to those used when working Use steps similar to those used when working

with “automatic thoughts”with “automatic thoughts” Beliefs about powerBeliefs about power

Help the person develop better coping tools Help the person develop better coping tools and so increase personal power in relation to and so increase personal power in relation to the voicesthe voices

Beliefs about identityBeliefs about identity Explore interpretations, and evidence for Explore interpretations, and evidence for

interpretations, that are less distressinginterpretations, that are less distressing

Beliefs about the identity of voicesBeliefs about the identity of voices The most helpful beliefs are those that The most helpful beliefs are those that

give the person a sense of power in give the person a sense of power in relation to the voicerelation to the voice

It might be important to explore the It might be important to explore the advantages and disadvantages of certain advantages and disadvantages of certain beliefs, not just the evidence for and beliefs, not just the evidence for and againstagainst

Don’t insist on a scientific understandingDon’t insist on a scientific understanding As long as a person gains a sense of power in As long as a person gains a sense of power in

relation to the voice, he or she may be finerelation to the voice, he or she may be fine

Other factors addressed by Other factors addressed by cognitive therapy for psychosiscognitive therapy for psychosis

The emotional arousal that underlies many The emotional arousal that underlies many of the more obvious “psychotic symptoms”of the more obvious “psychotic symptoms”

The sense of defeat that often underlies The sense of defeat that often underlies “negative symptoms”“negative symptoms”

Social anxiety and social withdrawalSocial anxiety and social withdrawal Apparently disorganized thinkingApparently disorganized thinking Paranoia, which is seen as on a spectrum Paranoia, which is seen as on a spectrum

with everyday anxiety & trust issueswith 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.