Cognitive Therapy for Psychosis An Individualized Approach for

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Cognitive Therapy for Psychosis An Individualized Approach for “Extreme States” Presenter: Ron Unger LCSW

Cognitive Therapy for Psychosis An Individualized Approach for “Extreme States” Presenter: Ron Unger LCSW 541 -513 -1811 4 ronunger@gmail. com

Cognitive therapy for psychosis Ø Is a systematic approach l With published therapy manuals

Cognitive therapy for psychosis Ø Is a systematic approach l With published therapy manuals • Though treatment requires an individualized approach, more so than in other varieties of cognitive therapy Ø Is well researched l At least 36 randomized studies • Showing significant effects on average l l (Beck, 2009) Is recognized as an “evidence based practice”

The Essential idea of Cognitive. Behavioral Therapy: Ø If you learn to think and

The Essential idea of Cognitive. Behavioral Therapy: Ø If you learn to think and act differently, then your mental and emotional problems may disappear Ø You can learn to take responsibility for changing your thoughts and behaviors l though you may need others to help you figure out how to do it

From an “Illness Management & Recovery” workbook Ø “What causes schizophrenia? l “Schizophrenia is

From an “Illness Management & Recovery” workbook Ø “What causes schizophrenia? l “Schizophrenia is nobody’s fault. This means that you did not cause the disorder, and neither did your family members or anyone else. Scientists believe that the symptoms of schizophrenia are caused by a chemical imbalance in the brain. ” P. 177 of workbook at http: //www. ncebpcenter. org/pdfs/wmrdox/wmr. handouts. pdf

The extreme version of the “Medical Model” tries to relieve shame & blame, but

The extreme version of the “Medical Model” tries to relieve shame & blame, but it goes too far: 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” Cognitive model: “You aren’t to blame for falling into this problematic pattern, you didn’t know how to anticipate it, but with effort and with help you may learn to get out of it” 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 Therapy and Medications Ø The evidence base is mostly with clients who also

Cognitive Therapy and Medications Ø The evidence base is mostly with clients who also took medications l Cognitive therapy worked to reduce the symptoms the medication did not control Ø As a result of cognitive therapy, clients are often able to use less medication Ø Case study reports show cognitive therapy is often helpful with clients who refuse medications. Ø One smaller study showed CBT was helpful for clients who chose not to use medication Morrison et al, 2012

Graph as printed in “Anatomy of an Epidemic” by Robert Whitaker

Graph as printed in “Anatomy of an Epidemic” by Robert Whitaker

GD = Guided Discontinuation MT = Maintenance Therapy See Wunderink, L. , Nieboer, R.

GD = Guided Discontinuation MT = Maintenance Therapy See Wunderink, L. , Nieboer, R. M. , Wiersma, D. , Sytema, S. , & Nienhuis, F. J. (2013). Recovery in Remitted First-Episode Psychosis at 7 Years of Follow-up of an Early Dose Reduction/Discontinuation or Maintenance Treatment Strategy: Long-term Follow-up of a 2 -Year Randomized Clinical Trial. JAMA Psychiatry, 70(9), 913 -920. doi: 10. 1001/jamapsychiatry. 2013. 19

Definition of “psychosis” Ø "A severe mental disorder, with or without organic damage, characterized

Definition of “psychosis” Ø "A severe mental disorder, with or without organic damage, characterized by derangement of personality and loss of contact with reality and causing deterioration of normal social functioning. “ l From the American Heritage Stedman Medical Dictionary

A Relational Definition of Psychosis Ø We call it psychosis when l l we

A Relational Definition of Psychosis Ø We call it psychosis when l l we don’t understand someone’s experience and/or behavior, and we don’t have a better explanation for why we don’t understand them • (paraphrase of a remark by Andrew Moskowitz) Ø So it may be about the problems or limits with our understanding, and not just the problems or limits of the person labeled “psychotic”

Social Support and Dialogue Ø Easily available to those who are “normal” Ø More

Social Support and Dialogue Ø Easily available to those who are “normal” Ø More difficult to find for those who are “neurotic” Ø Very difficult or impossible to find for those who are “psychotic” Ø The more you need it, the less available it is

Psychosis contributes to often extreme social isolation Isolation increases likelihood of psychotic symptoms Isolation

Psychosis contributes to often extreme social isolation Isolation increases likelihood of psychotic symptoms Isolation as contributing cause to psychosis: see http: //isps-us. org/koehler/sociocultural. htm

Dialogue and the Edge between Balance and Imbalance Ø Rationality emerges out of dialogue

Dialogue and the Edge between Balance and Imbalance Ø Rationality emerges out of dialogue Not by suppressing "irrational" views Ø Health is not the absence of disruptive emotions and thoughts l But rather a meta-balance between what is disruptive and what is stabilizing l

Two extremes, when good internal dialog is missing: Fusion: Mindful Dialogue: My emotions or

Two extremes, when good internal dialog is missing: Fusion: Mindful Dialogue: My emotions or thoughts take over, or tell me what is real: I include all of my emotions & the thoughts associated with them in an ongoing internal dialogue. If I'm feeling down then I'm doing terrible, if I feel scared, then I’m in danger, etc. Decisions about what to do emerge from this process. Experiential Avoidance: I reject my feelings or thoughts, or see them as my enemy: I need to block them out (or drug them away)

One thing that can disrupt internal dialog: Trauma Ø When arousal is too great,

One thing that can disrupt internal dialog: Trauma Ø When arousal is too great, parts of the mind that generate internal dialog evaluating danger can shut down (van der Kolk, 2006) l l Ø Which can be good in extreme situation Problem is when it doesn’t start up again afterward When experience seems too much to face, long term problems can result l l Not just PTSD A host of other problems, including “psychotic symptoms” – (John Read, 2008)

What is most essential to CBT for Psychosis: Ø Establishing and maintaining a good

What is most essential to CBT for Psychosis: Ø Establishing and maintaining a good relationship is more important than any otherapeutic activity l So if anything you are doing interferes with the relationship, stop it! • at least until you find a way to do it that does not interfere with the relationship From the book “Cognitive Therapy of Schizophrenia” by Kingdon & Turkington, p 43

Another fundamental ingredient: Hope Ø Modern finding: that mental activity can change biochemistry and

Another fundamental ingredient: Hope Ø Modern finding: that mental activity can change biochemistry and eventually brain structure l l This finding is known as “neuroplasticity” A reason for hope Ø Not really more mystical than the notion that bodily activity can change the body, i. e. , exercise changes muscles, etc.

Key Elements of the Cognitive Approach Ø Goals structured around what client wants Ø

Key Elements of the Cognitive Approach Ø Goals structured around what client wants Ø Curiosity about client’s efforts to make sense Ø Collaborative Empiricism Ø Socratic Dialogue Ø Middle ground between confrontation and appearing to confirm beliefs Ø Empathy

CBT for psychosis includes “off the map” exploration: Therapy by formula: I just do

CBT for psychosis includes “off the map” exploration: Therapy by formula: I just do what is in therapy manual, whether it works or makes sense to the individual client or not. I always know exactly what I am doing though. Follows charted routes when that makes sense, but also willing to explore uncharted territory: When I explore uncharted territory, I tend to make charts as I go as much as I can. Meander therapy: I set off not knowing where I am going, get there & don’t know where I am, then get back and don’t know where I’ve been.

Exercise Ø “Client” chooses a very controversial or even “psychotic” belief Ø “Therapist” engages

Exercise Ø “Client” chooses a very controversial or even “psychotic” belief Ø “Therapist” engages in discussion using “collaborative empiricism” l l l Avoid confrontation or collusion First, briefly explore why “client” believes it Then, gently draw out from the “client” any possible reasons someone might doubt that the belief is completely true Ø Remember, Relationship First!

Normalization: Noticing How Psychotic Experiences Are: Ø Common Ø Possibly caused by many everyday

Normalization: Noticing How Psychotic Experiences Are: Ø Common Ø Possibly caused by many everyday factors Ø Similar to & on a continuum with other human difficulties Ø Something that can be successfully coped with l Often using already existing skills Ø Experiences that may have a positive side

Purposes of Normalizing Ø Lower negative arousal & fear l l That can otherwise

Purposes of Normalizing Ø Lower negative arousal & fear l l That can otherwise lead to more psychosis Reduce self stigma Introduce culturally acceptable interpretations Help link to possible coping skills

DIALECTICAL BEHAVIOUR THERAPY: Linehan’s STATES OF MIND applied to PSYCHOSIS Slide by Isabel Clarke

DIALECTICAL BEHAVIOUR THERAPY: Linehan’s STATES OF MIND applied to PSYCHOSIS Slide by Isabel Clarke and Donna Rutherford

When to do Normalizing Ø Normalizing is woven throughout all of CBT for psychosis

When to do Normalizing Ø Normalizing is woven throughout all of CBT for psychosis l Starting with conversations during the assessment Ø To be effective with it l Normalizing also has to be woven into how therapist thinks about psychosis

Experiences on a Continuum Ø Psychosis as an extreme version of everyday problems in

Experiences on a Continuum Ø Psychosis as an extreme version of everyday problems in functioning l not exotic symptoms imposed on the personality Ø Tipping Points l New or strange problems can emerge when an everyday process goes “too far”

A key normalizing message (Van Os, 2006) Normalising …. approximately 8% of the population

A key normalizing message (Van Os, 2006) Normalising …. approximately 8% of the population will experience an episode of voice hearing…… Causes: - sleep deprivation, grief, undisclosed trauma, emotional abuse, bullying, hallucinogens. Copyright 2014 The Insight CBT Partnership

Copyright 2014 The Insight CBT Partnership

Copyright 2014 The Insight CBT Partnership

Jesus Beethoven (composer) Zoe Wanamaker (actress) Anthony Hopkins (actor) Sigmund Freud (psychoanalyst) Brian Wilson

Jesus Beethoven (composer) Zoe Wanamaker (actress) Anthony Hopkins (actor) Sigmund Freud (psychoanalyst) Brian Wilson (Beach Boys) Joan of Arc (saint and heroine of France) John Frusciante (guitarist, Red Hot Chili Peppers) Copyright 2014 The Insight CBT Partnership

Language use: Ø Abnormalizing: exaggerating the difference between normal and psychotic Ø Normalizing: acknowledging

Language use: Ø Abnormalizing: exaggerating the difference between normal and psychotic Ø Normalizing: acknowledging the ambiguity, the commonalities l Questioning mental health jargon & categories

External World Spontaneous imagination That which one consciously identifies with Impulse Emotion Memories Thought

External World Spontaneous imagination That which one consciously identifies with Impulse Emotion Memories Thought “Inner” Voice Internal representations of others Our culture expects us to define anything that is not “the external world” as part of our wider self, even if we didn’t choose it and it was triggered by the external world.

External World Evil Spirits That which one consciously identifies with Aliens Voice that isn’t

External World Evil Spirits That which one consciously identifies with Aliens Voice that isn’t part of me… Telepathy Brain Implant Witchcraft Satan Examples of interpretations of inner experiences as being sourced in something other than the self

External World Mental Illness That which one consciously identifies with Chemical Imbalance Misfiring synapses

External World Mental Illness That which one consciously identifies with Chemical Imbalance Misfiring synapses “Symptoms” Neurological Brain Disease “Mental illness” explanations continue the trend of defining experiences as not belonging within the self, but with different names and categories……. notice how the wider self is now polluted with “illness”

Some Considerations Ø Can normalizing include talking about “illness”? Ø Is it possible to

Some Considerations Ø Can normalizing include talking about “illness”? Ø Is it possible to take normalizing too far, resulting in l l l Minimizing the problem “Colluding” in the denial of the problem Or being perceived as lacking empathy?

Does Psychosis Always Require Treatment? Ø The vast majority of psychotic experiences may resolve

Does Psychosis Always Require Treatment? Ø The vast majority of psychotic experiences may resolve on their own l l Normalizing may play a key role in that It’s the failure to find a way to normalize that leads to need for treatment Ø Attempts to control mental content may seriously backfire l “It’s normal for some of our thoughts to be weird” may be a better perspective

More Stress Increased emotional arousal hypervigilance, listening harder for more voices Vicious Circle Hearing

More Stress Increased emotional arousal hypervigilance, listening harder for more voices Vicious Circle Hearing a voice Interpret voice itself as a threat

Less Stress Accept the voice as a useful signal of stress, take action that

Less Stress Accept the voice as a useful signal of stress, take action that reduces the stress Virtuous Circle Less trouble from Hearing a voice Interpret the voice as an effect of stress or as a source of information about aspects of self

Developing a formulation Ø A formulation is a hypothesis or story about l l

Developing a formulation Ø A formulation is a hypothesis or story about l l what caused problems to develop, and what maintains the problems Ø The formulation provides l l hope that the problem can be overcome, as well as suggestions about how to do that

What’s causing these weird experiences? Therapist: We can diagnose you with the illness called

What’s causing these weird experiences? Therapist: We can diagnose you with the illness called schizophrenia because you have these weird experiences. Therapist: These weird experiences are being caused by your illness, which is schizophrenia Client: How do you know that I have an illness called schizophrenia? Problems occur when a “diagnosis” is used as an explanation for the problem

The traditional explanation is linear and offers little hope for recovery From “Madness Explained”

The traditional explanation is linear and offers little hope for recovery From “Madness Explained” by Richard Bentall

Mostly Biological Model of Causality in “Mental Illness” Popular Today Biological Person’s mental activity

Mostly Biological Model of Causality in “Mental Illness” Popular Today Biological Person’s mental activity and behavior Psychological Social/ environmental Social etc.

A Truly Bio-Psycho-Social Model of Causality in “Mental Illness” Biology Biological Person’s mental activity

A Truly Bio-Psycho-Social Model of Causality in “Mental Illness” Biology Biological Person’s mental activity and behavior Psychological Social/ environmental Social etc.

From: A Casebook of Cognitive Therapy for Psychosis, Edited by Anthony P. Morrison

From: A Casebook of Cognitive Therapy for Psychosis, Edited by Anthony P. Morrison

A-B-C formulation for voices Copyright 2014 The Insight CBT Partnership

A-B-C formulation for voices Copyright 2014 The Insight CBT Partnership

Voices model Stress/ Cannabis Hears voices Fear No sleep Put silver paper on windows.

Voices model Stress/ Cannabis Hears voices Fear No sleep Put silver paper on windows. Monitor UFO site. “It is the voice of aliens who want to experiment on me” Copyright 2014 The Insight CBT Partnership

Friends see you as paranoid, turn against you, more betrayal Accuse friends of betrayal

Friends see you as paranoid, turn against you, more betrayal Accuse friends of betrayal Being hurt in the past, betrayed by friends See betrayal as happening at times even when it likely isn’t Get very attentive to possible clues betrayal could be happening, “paranoia makes me safe” Want to make sure it doesn’t happen again Try even harder to make sure betrayal doesn’t happen again Paranoia escalates

A key thing to look for in a formulation: Ø When efforts to make

A key thing to look for in a formulation: Ø When efforts to make things better are inadvertently making it worse l As things get worse, misguided efforts to make them better often intensify • Leading to things getting even worse Ø Without insight into the vicious circle, it just accelerates l Or is perceived to be definitely a result of a “biologically based mental illness”

(Gumley, Braehler, Laithwaite, Mac. Beth, & Gilbert, 2010)

(Gumley, Braehler, Laithwaite, Mac. Beth, & Gilbert, 2010)

A Developmental Formulation Negative identity defined by others, felt crushed Learned how to make

A Developmental Formulation Negative identity defined by others, felt crushed Learned how to make up own identity, own world view (drugs amplified this) Often overdid it, getting grandiose or nonsensical, rejecting reason entirely Others couldn’t understand, often had poor relationships But Found some others who could understand & appreciate self, Felt inspired to make more sense to others, resulting in more coherent identity

“Madness” that leads to fun, changes seen as positive, and/or notable cultural influence –

“Madness” that leads to fun, changes seen as positive, and/or notable cultural influence – how different is it from madness that just causes trouble and is labeled “sick? ”

A less extreme story leaves more room for growth & development “Psychotic” story: I

A less extreme story leaves more room for growth & development “Psychotic” story: I have to believe this story for important emotional reasons, even if it gets me into serious trouble 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 Psychiatric story: my beliefs and experiences are caused by my disease, for example, schizophrenia

Voices, Visions, and Other “Hallucinations” Ø Cognitive therapists see these as just a person’s

Voices, Visions, and Other “Hallucinations” Ø Cognitive therapists see these as just a person’s own thoughts or imaginings about something in the world, l temporarily mistaken for perceptions coming in directly from the external world • See Cognitive Therapy for Schizophrenia” Kingdon & Turkington, p 22 See l Different in style – “dreaming while awake”

3 rd Wave of CBT: Not about “getting rid of” the “symptom” Ø Instead

3 rd Wave of CBT: Not about “getting rid of” the “symptom” Ø Instead l l Avoid letting it have too much influence While also accepting its existence • As one focuses on living a valued life Ø And l Being open to the possibility that the “symptom” if properly understood • May actually make a contribution to that valued life

Hypervigilant: Afraid of not seeing a threat that may be present Anxious, aroused, perceiving

Hypervigilant: Afraid of not seeing a threat that may be present Anxious, aroused, perceiving a threat in the absence of good evidence Blocks out or looks away from signs of danger Interprets self as overreacting: afraid of going mad or appearing mad Confusion caused by coexistence of hypervigilance and blocking perceptions, otherwise known as “vigilance-avoidance”

From the book “Cognitive-Behavior Therapy for Severe Mental Illness” by by Jesse H. Wright,

From the book “Cognitive-Behavior Therapy for Severe Mental Illness” by by Jesse H. Wright, David Kingdon, Douglas Turkington, and Monica Ramirez

Supporting Integration Ø Untangling the relationship between inner experiences and outer reality l l

Supporting Integration Ø Untangling the relationship between inner experiences and outer reality l l Reality testing While being willing to explore important relationships with life experience Ø Supporting the person in l l thinking independently of voices etc. While also finding helpful ways of making meaning from them

Avoiding exposure to voice content can lead to prolonged vulnerability Ø When critical remarks

Avoiding exposure to voice content can lead to prolonged vulnerability Ø When critical remarks are avoided, it is difficult to put them into perspective l Most common coping tools: medications & distraction • Both involve avoidance of voice content Ø Contrast that with the “balanced view” l This values self-critical evidence & perspectives, but is not dominated by them

Coping Strategies Ø No one option is best for all circumstances Ø Flexibility, fitting

Coping Strategies Ø No one option is best for all circumstances Ø Flexibility, fitting the best strategy to the circumstance, is key Ø A common problem is when someone relies too much on one or two methods, with little access to other methods l CBT therapists call this the problem of “overdeveloped” and “underdeveloped” coping strategies l See the book “Staying well after psychosis” by Gumley & Schwannauer, p. 193 -195

Definition of “Paranoia” Ø A psychotic disorder characterized by systematized delusions, especially of persecution

Definition of “Paranoia” Ø A psychotic disorder characterized by systematized delusions, especially of persecution or grandeur, in the absence of other personality disorders. Ø Extreme, irrational distrust of others. l From The American Heritage® Stedman's Medical Dictionary Ø (Note that any kind of interpersonal anxiety is on a continuum with “paranoia”)

Normalizing: Understanding the Possible Roles of Paranoia Ø Helps us detect threats l Can

Normalizing: Understanding the Possible Roles of Paranoia Ø Helps us detect threats l Can make us feel safer • “they won’t slip anything past me” Ø Gives us someone else to blame l “I’m very competent, but there’s trouble because all these people are against me”

When paranoia is protecting self esteem: Ø Then directly challenging paranoid beliefs may threaten

When paranoia is protecting self esteem: Ø Then directly challenging paranoid beliefs may threaten self esteem l So first develop alternative ways to protect a sense of self worth • then can realistically look at evidence for and against paranoid views

Traditional Definition of a “Delusion” "A delusion is a false belief held with absolute

Traditional Definition of a “Delusion” "A delusion is a false belief held with absolute certainty despite evidence to the contrary and out of keeping with the person's social, educational, cultural and religious background” Hamilton, 1984, as quoted in “Cognitive Therapy of Schizophrenia” by Kingdon & Turkington

A couple ways CBT looks at “delusions” differently Ø People may claim 100% certainty,

A couple ways CBT looks at “delusions” differently Ø People may claim 100% certainty, and seem to ignore evidence, l but when encouraged to be thoughtful, they often change beliefs at least somewhat Ø There may be a grain of truth (or sometimes much more) in apparently delusional beliefs l Or a belief may be metaphorically true, even though literally false

Four ways of working with probable delusions: Ø 1. Helping the person discover ways

Four ways of working with probable delusions: Ø 1. Helping the person discover ways to live more successfully while continuing to have the belief Ø 2. Explore what preceded the belief, and how it developed l This means exploring both • What was going on in the person’s life which may have created a dilemma to which the belief was a solution • How the belief may have been a way of making sense of difficult experiences at the time

Four Ways, Continued Ø 3. Find, explore, and help the person cope with vulnerabilities

Four Ways, Continued Ø 3. Find, explore, and help the person cope with vulnerabilities that may underlie the belief Or, consider that the belief may be a somewhat disguised way to bring up concerns, and look for more direct ways to address those issues Ø 4. Evaluate at least parts of the belief by • exploring evidence for and against • developing self-esteem preserving alternatives • testing aspects of the belief l l Avoid head-on confrontations with entrenched beliefs

Moving Forward Without Changing the Belief Ø Pay attention to exactly how having the

Moving Forward Without Changing the Belief Ø Pay attention to exactly how having the belief is causing trouble l l Then be curious about all the possible ways such trouble might be avoided Wonder about, how do others with similar beliefs get by in the world? Ø Moving on with life despite the belief may reduce preoccupation with it l And reduced preoccupation may make it easier to move on with life!

Exploring the Origins of a Belief Ø Understand the person’s life story up until

Exploring the Origins of a Belief Ø Understand the person’s life story up until the belief l Especially events & issues immediately preceding its formation Ø As well as the chain of events and interpretation of events that led directly to the belief Ø Also notice what got better, what got worse as belief emerged

Developing Better Ways to Cope With Vulnerabilities Ø If a belief is protective in

Developing Better Ways to Cope With Vulnerabilities Ø If a belief is protective in some way l You may be able to help the person get to where they don’t need that protection Ø If the belief is an exaggerated form of some kind of fear l You may be able to help with what underlies this Ø Solving problems with insomnia, substance use, isolation etc. can be helpful

When you are ready to weigh the evidence: Ø Be curious about details and

When you are ready to weigh the evidence: Ø Be curious about details and inconsistencies Ø Ask what was most puzzling about experiences that led to the belief Ø Notice “safety behaviors” that may be impeding collection of disconfirming evidence Ø Find ways to gather more data, conduct tests, etc.

Flashbacks to bad memories Worries plus imagination Once the person can see a lot

Flashbacks to bad memories Worries plus imagination Once the person can see a lot of possibilities, can have them draw a pie chart, with space for the likelihood of each one….

Psychotic experience and spirituality: Ø The presence of some distressing “psychotic” experience does not

Psychotic experience and spirituality: Ø The presence of some distressing “psychotic” experience does not mean the person cannot also have helpful spiritual experiences (often mixed together. ) Ø What therapist can do l Help person distinguish helpful from unhelpful experiences and interpretations • Being curious about times of possibly “mind too open” and/or of “mind too closed” l Exploring inconsistencies with the person’s own spiritual traditions can be one way of helping the person see additional options

Exercise Ø One person role plays someone with a delusional belief l who is

Exercise Ø One person role plays someone with a delusional belief l who is open to gathering more evidence to show whether or not it is true Ø Other person plays therapist l l Collaborate in devising ways to collect evidence, or perform experiments Can also explore obstacles to this exploration, and how various outcomes might be interpreted

Understanding Thought Disorder: Ø Disordering thought can serve some functions, such as: l communicating

Understanding Thought Disorder: Ø Disordering thought can serve some functions, such as: l communicating something the person cannot express any other way • Such as expressing a person’s sense of overwhelm when no ordered approach seems adequate l l getting close to an emotionally charged issue, then skipping away appearing hyper-intelligent, creative, or deliberately frustrating someone who is trying to follow along

Key ideas for working with disorderly thinking Ø Communicate your intent to understand Ø

Key ideas for working with disorderly thinking Ø Communicate your intent to understand Ø Watch for themes, non-verbal signs, ask for clarification where possible Ø Let the person see what you are understanding & what you are confused about Ø Most of all, don’t pretend to understand when you don’t!

Negative symptoms Ø Such l l l things as: not showing much affect not

Negative symptoms Ø Such l l l things as: not showing much affect not speaking much low activity, social withdrawal not paying attention Ø Understood by cognitive therapists as behaviors, or absence of behavior, that the client often uses to reduce stress Ø “Cognitive Therapy for Schizophrenia” Kingdon & Turkington, p 140

Notices failure acutely, sees few successes to offset the failures Absence of skills makes

Notices failure acutely, sees few successes to offset the failures Absence of skills makes failure more common when activities are attempted Cycle of “negative symptoms” High awareness of personal failures leads to not attempting much Absence of attempts leads to failure to develop skills

Cognitive Systemic Considerations Describing an overly stress-inducing approach by the parents Adam’s Behaviour Staying

Cognitive Systemic Considerations Describing an overly stress-inducing approach by the parents Adam’s Behaviour Staying in bedroom a lot, sleeping long hours. Adam’s Interpretation They’re not bothered about me at all. No one cares Parents’ Interpretation He’s so lazy, He’s just not trying Parents’ Behaviour Nag him Tell him he’s lazy and a waste of space Copyright 2014 The Insight CBT Partnership

Cognitive Systemic Considerations Describing an overly disengaged approach by the parents Adam’s Behaviour Staying

Cognitive Systemic Considerations Describing an overly disengaged approach by the parents Adam’s Behaviour Staying in bedroom a lot, sleeping long hours. Adam’s Interpretation Every one has given up on me, feels like my life is over Parents’ Interpretation Schizophrenia has changed Adam, he’s doing so poorly now. Parents’ Behaviour Leave him alone Don’t encourage him to engage in more activities Copyright 2014 The Insight CBT Partnership

Working with negative symptoms: Ø Use a very low stress approach: l Get family

Working with negative symptoms: Ø Use a very low stress approach: l Get family on board with this Ø But also support activity & positive structured routines Ø Nurture dreams and purpose Ø Consider the possibility that medication may be aggravating negative symptoms See the book “Cognitive Therapy of Schizophrenia” by Kingdon & Turkington, p 138 -148

Focuses more attention on successes, even if small Presence of skills makes success more

Focuses more attention on successes, even if small Presence of skills makes success more common when activities are attempted Cycle of recovery from “negative symptoms” High awareness of successes leads to attempting more More attempts leads to developing skills

Relapse Prevention Ø Watching for signs of moving toward relapse l Such as general

Relapse Prevention Ø Watching for signs of moving toward relapse l Such as general signs of psychological distress, and/or low level psychotic symptoms Ø Detecting & treating warning signs is an effective way of preventing relapse Ø Avoid extremes in relapse prevention l Like oversensitivity to seeing minor mental/emotional variations as signs of imminent relapse • This feeds anxiety which makes relapse more likely! See the book “Cognitive Therapy of Schizophrenia” by Kingdon & Turkington, p 158 -164

3 levels of possible integration with rest of the mental health system 1. Cognitive

3 levels of possible integration with rest of the mental health system 1. Cognitive therapy used for medicationresistant symptoms Ø 2. Cognitive therapy made available to all who have psychotic experiences, Ø l Ø usually alongside medications but often resulting in lower doses being used 3. Cognitive therapy and other psychosocial interventions seen as primary l with medications used only when psychosocial interventions prove inadequate.

Integrate working with the family Ø One way cognitive therapists work with families differs

Integrate working with the family Ø One way cognitive therapists work with families differs from that of “psychoeducational” approaches l Instead of asking family not to criticize because client is “ill” and cannot control him or her self • Help family understand why client is acting how they are, and how criticism is currently impacting them l This may have more long term effectiveness See the book “Cognitive Therapy for Psychos: A Formulation-Based Approach” by Morrison et al, p 228 -229

Relating to other professionals who may be skeptical Ø Pay attention to ways these

Relating to other professionals who may be skeptical Ø Pay attention to ways these professionals may be distressed l And how your new ideas and methods can be helpful in relieving that distress Ø Seek collaborative dialogue l l Balance between confrontation and collusion Acknowledge their points but insist on also attending to contradictory evidence

Homework Ø Why use it: l l Gets client active in therapy process Appears

Homework Ø Why use it: l l Gets client active in therapy process Appears that in general cognitive therapy that uses homework is 60% more effective • (Glaser, N. M. , Kazantzis, N. , Deane, F. P. , & Oades, L. G, 2000) Ø Types of homework: l l l Information collection Experiments Practice new skills

Homework and session structure: Ø Suggested session structure: l l l Review client’s state

Homework and session structure: Ø Suggested session structure: l l l Review client’s state Set the agenda with client Reviewing homework is “almost always” next Work on the agenda items Agree on homework for next time Elicit feedback about the session See the book “Cognitive Therapy for Psychos: A Formulation-Based Approach” by Morrison et al, p 90 -94

7 golden rules of homework compliance Ø Decide on work to be done jointly

7 golden rules of homework compliance Ø Decide on work to be done jointly Ø Clearly identify the rationale for doing it Ø Check out obstacles Ø Make it meaningful but achievable Ø Establish prompts Ø Begin use of homework in first session Ø If it doesn’t get done, explore why, and do it during the session if possible See the book “Cognitive Therapy for Psychos: A Formulation-Based Approach” by Morrison et al, p 117 -118

Your Homework: Doing Something Different Ø What are one or two things you want

Your Homework: Doing Something Different Ø What are one or two things you want to do differently in your practice based on what you learned today? Ø What obstacles to making those changes can you see? l Ø What strategy can you use to get over those obstacles? Monitor your progress: l Put a date in your calendar, with an alarm, for you to • review your progress • Make your plan for a next step