Psychological therapy in early psychosis

David Fowler

Reader in Clinical Psychology, UEA

Consultant Clinical Psychologist, NMHCT

What I will talk about

• What is CBT for psychosis and are there different types of CBT?

• Do we need different therapies for different phases of early psychosis?

• The case for the use of specific psychological interventions and current research

Acknowledgements

• Norfolk Early Intervention service colleagues: Dr Iain Macmillan, Nick Bishop, Mark Wright, Peter Edge, Ruth Lin, Jane Wallace...and new....,

• UEA colleagues and Doctoral students: Mike Day, Claire Harrison, Sam Vaughan, James Plaistow

• PRP (Welcome Trust programme grant) colleagues: Philippa Garety, Elizabeth Kuipers, Paul Bebbington,

Graham Dunn, Rebbecca Rollinson et al...

Young people with early psychosis

• Have episodes of severe disturbances in thought, emotion and behaviour (delusions and hallucinations)

• Most recover from such episodes but some remain socially disabled and depressed

• Some are at high risk of developing chronic syndromes with need for repeated hospitalisation and high service use

• need specialised multidisciplinary care due to the complexity of their problems and “difficult to treat” presentations

Ben came into contact with mental health services because his mother was worried about him. He had recently left home to live in a bed-sit. He had become increasingly disorganized. His flat walls were covered in paintings and he was pre-occupied with drawing, not sleeping and not eating or looking after himself. He talked in a bizarre way about God, good and evil and about how his task was to save the world. He said that painting helped him to make sense of things. He was clearly listening to voices. He said these were God and the Devil talking to him. He said he didn't need any help.

Ben

A psychological perspective

Psychosis as a life crisis which sets a series of adaptive demands for the individual

Making sense of psychosis: formulating psychotic problems

• Normal models of adaptation to stress

• Vulnerability stress models

• Cognitive models of psychotic symptoms

The evolution of voices and delusional beliefs

The cognitive model of psychosis and its clinical implications

• The cognitive perspective suggests that psychosis is more amenable to understanding than is commonly believed

• Helping people understand the nature of their personal vulnerability to psychosis is a core process of cognitive therapy

• Cognitive therapy involves helping people to become aware of errors in the way they think about psychotic experience to compensate for these

• The aim is to help the person construct a less distressing and more adaptive way of understanding their predicament

Cognitive Behaviour Therapy

• Works from the patient’s point of view• Is collaborative• Builds up strengths (does not strip away defences) • Builds on good basic psychotherapeutic skills (warmth,

empathy, concern)• Central task is making sense of and explaining psychosis • Process of therapy, strategy and use of techniques is

guided by individualised assessment and formulation

The six stages of Cognitive Behaviour Therapy for Psychosis

Engagement and assessment

Promoting self regulation of psychotic symptoms

Developing a shared model of psychosis

Addressing delusions and beliefs about voices

Addressing dysfunctional assumptions about self and others

Addressing social disability and risk of relapse

Adaptations in working with people with persistent voices and delusions

• People with high conviction in delusions typically lack of a shared rationale with therapists

• People with voices typically do not regard them as symptoms

• Overcoming dissonance and working from the patients perspective is key

• Flexibility, individualisation, and careful attention to engagement is required

•

Mean item ratings block one (n= 71)

Recognising problemsEngagement

columbo stylenormalising

resolving ambivalencassessing psychoticdeveloping a narrati

developing a model oEvidence for delusioVerbal challenge of

Validity testingEnhancing self-regul

Schema workAnxiety work

Depression workVoices and other hal

DelusionsAssessment of previo

Formulating personalRelapse prevention i

Relapse cognitions

Mean

2.52.01.51.0.50.0

Engagement

Assessment

Narrative Work

Means all items block two (n = 29)

Recognising problemsEngagement

columbo stylenormalising

resolving ambivalencassessing psychoticdeveloping a narrati

developing a model oEvidence for delusioVerbal challenge of

Validity testingEnhancing self-regul

Schema workAnxiety work

Depression workVoices and other hal

DelusionsAssessment of previo

Formulating personalRelapse prevention i

Relapse cognitions

Mean

2.52.01.51.0.50.0

Engagement

Assessment

Formulation

Schema work

Means all items block three (n=20)

Recognising problemsEngagement

columbo stylenormalising

resolving ambivalencassessing psychoticdeveloping a narrati

developing a model oEvidence for delusioVerbal challenge of

Validity testingEnhancing self-regul

Schema workAnxiety work

Depression workVoices and other hal

DelusionsAssessment of previo

Formulating personalRelapse prevention i

Relapse cognitions

Mean

2.52.01.51.0.50.0

Engagement

Strategies

Formulation

Means all items block four (n=11)

Recognising problemsEngagement

columbo stylenormalising

resolving ambivalencassessing psychoticdeveloping a narrati

developing a model oEvidence for delusioVerbal challenge of

Validity testingEnhancing self-regul

Schema workAnxiety work

Depression workVoices and other hal

DelusionsAssessment of previo

Formulating personalRelapse prevention i

Relapse cognitions

Mean

2.52.01.51.0.50.0

Engagement

Strategies

Formulation

Relapse prevention Interventions

CBT for psychosis?

CBT for psychosis: a better analogy

Does CBT work?Published trials with people with treatment

resistant psychosis

Effect size

• London-East Anglia trial: CBT versus case management 0.86 (Kuipers, Fowler, Garety et al, Brit. J Psychiatry,1997; 1998) (9 months individually formulated CBT) 29% improvement in BPRS symptom ratings 65% CBT versus 17% CM made 25% improvement in symptoms • Manchester trial: CBT versus supportive counselling 0.57 (Tarrier et al; BMJ 1998; Brit. J Psychiatry,1999) (8 weeks, CBT package techniques) • Wellcome trial: CBT versus befriending 1.18 (Sensky, Turkington, Kingdom et al, Arch.Gen, Psych 2000)

(9 months individually formulated CBT) .

Systematic review of trials of CBT (odds ratio)Participants receiving CBT have a 22% greater chance of

making a 50% improvement in mental state at post treatment than alternative condition

RCT of CBT to prevent relapse:The PRP project

Sample: People with psychosis presenting with second or subsequent acute psychotic relapse in 5 centres in London, Essex and Norfolk

Design 1) Alone: CBT vs TAU n=280 2) Family CBT vs FI vs TAU n=90 9 months treatment, 2 year f/uMeasures: 1) relapse, readmission, cost 2) symptoms, social functioning, quality of life 3) process measures

Recruitment at 11/03 n=212

CBT in relapse prevention (Gumley et al, 2003)

• Targeted at high risk of relapse groups• Therapy initiated at recovery: traditional CBT approach

(psychoeducation, warning signs, management of relapse, fear of relapse)

• Booster sessions at incipient relapse• At 12-months, 11 (15.3%) CBT group 19 (26.4%) TAU admitted• 13 (18.1%) CBT relapsed compared to 25 (34.7%) in TAU • CBT group showed greater improvement in negative symptoms (mean

difference CBT - TAU in change from baseline at 12 months -1.73, p = 0.035, 95% CI –3.33, -0.13), global psychopathology (-4.10, p = 0.0012, 95% CI –6.55, -1.65), performance of independent functions (2.70, p = 0.027, 95% CI 0.32, 5.08) and prosocial activities (3.99, p =0.0072, 95% CI 1.10, 6.88).

• (Rector and Beck, 2003, Schiz, Res., Sensky et al, 2001; also show benefits in negative symptoms, gen psychopathology from traditional CBT approach)

Conclusions

• There is strong evidence for effects of CBT on symptom reduction and distress with people who have distressing chronic treatment resistant psychotic symptoms

• There are promising indications of evidence for CBT in preventing relapse/readmission the PRP study will provide a definitive indication

What interventions for what stage of early psychosis ?

• At risk mental states - anomalous experiences. odd beliefs, distress

• First Episode - severe disturbances of thought, behaviour and affect

• Recovery - amotivation, depression, withdrawal• First admission- psychosis and the effects

hospitalisation• Second episode and relapse• Delayed recovery/ongoing psychosis-treatment

resistant symptoms, relapse, chronic emotional disturbance and social disability

The evidence basis for specific psychosocial interventions at different stages

• At Risk Mental States: 2 preliminary trials of CBT; further trials underway/planned

• First Episode: equivocal evidence for CBT-large trial (SoCRATES) suggests support = CBT

• Social recovery and depression: No trials-need for a new treatment (evidence for supported employment (IPS) in chronic cases, preliminary evidence for CBT on depression/negative symptoms)

• Relapse: good preliminary evidence: PRP trial will be definitive

• Delayed recovery and treatment resistant psychosis: evidence is strong, NICE suggest CBT should be provided

Problems in At Risk Mental States

“Something odd is going on” “I feel strange”

“I feel different from others” “I sense evil around” • Anomalous experiences• Search for meaning and delusional formation• Ongoing psychological difficulties• Engagement problems • Drug abuse

Therapy targets for early stage psychosis

• Establishing a relationship• Providing a framework for understanding

anomalies of experience• Decatastrophising and normalising• assisting the search for meaning• managing ongoing psychological problems

(anxiety/depression)• Promoting adaptive behaviour by behave expts • Structured short term therapy akin to

traditional CBT for anxiety/depression

Problems at the recovery stage

“I still feel ill” “Something’s wrong with me” “I’m not quite right” “I feel different to before”

“I'm fine” “I'm ok” “don’t want help” “just want to get on with my life”

• Amotivation• depression• social withdrawal and social disability• anomalies of experience and beliefs

• NB: These problems are often missed in people who may be described as doing ok

Outcomes at 2 years: First admission

psychosis cohorts in Norfolk (no EI service)

Measures: CAN, HoNoS, GAF, Health records Cohort 96/97 98/99No. 77 61Complete recovery (no relapse) 22% 17%Mod/severe ongoing psychosis 9% 37/9%Mod/severe Depression 60/28% 55/31%Number of unmet needs 5 5 Mean GAF 58 63None/ meaningful activity 60/15% 66/16%

The Issues

Suicide occurs in 10-15% of cases;mainly

in first 5 years . Parasuicidal risk averages 20-30% Rate of post psychotic depression in first-episodes: 25%-80%

Depression as a psychological reaction to psychosis and trauma: recent

psychological studies• Depression in early psychosis is associated with increased

loss shame humiliation and entrapment and lower social comparison (Iqbal et al, 2001; Plaistow and Fowler, submitted)

• Depression, negative symptoms and social disability are strongly associated with each other at the recovery stage and also with the degree to which individuals can see themselves in meaningful roles and goals in the future (Day and Fowler, Submitted)

• Depression is associated with reporting intrusive memories and avoidance of traumatic events (Fowler et al, In Press)

So, what does all this mean for early intervention??

• Amongst cases apparently symptomatically stable (in between psychotic episodes)

• we need to monitor and target depression and hopelessness, and prevent appraisals of loss shame and entrapment

• We need to carefully target patterns of social avoidance which may emerge initially as protective

Individual placement and support

• Vocational workers focussing on social recovery who have links to employers and knowledge of employment issues work alongside case managers as part of an assertive outreach team (Bond)

• Hartford study (Mueser et al, J.Cons Clin Psychol, In Press) IPS (373 days employed) vs 176 days standard treatment

• Crowther et al BMJ, 2001 systematic review

Developing Individual Placement and Support

• Effects are on low paid service sector employment which is transitive

• Needs attention to meaningful goals and career pathways

• At present suitable for people who are fully recovered ready to work

• Can psychological therapy prepare more people for IPS?

• Factors involved include hopelessness, amotivation, cognitive deficits and depression

The case for Social Recovery oriented CBT in early psychosis

• We need a new treatment which offers social opportunities while addressing psychological problems including depression, social avoidance

• Ideally this will combine best practice in vocational interventions (IPS) with structured psychological interventions (CBT)

• This treatment is in the early stages of development

Key psychosocial interventions in Early intervention in psychosis to include:

• Support through the acute phase in least restrictive supportive therapeutic settings

• CBT for delayed recovery: treatment resistant psychosis and relapse

• Social recovery intervention: Case managers providing an assertive vocational recovery programme addressing depression and anxiety in collaboration with supported employment/education/leisure.

• User and family support and psyched groups• Family work

• With protocol driven psychopharmacology

And it should all lead to.....

• a much better social and symptomatic long term outcome for young people with severe mental illness