An Introduction to Cognitive Behavioral Therapy for Psychosis - PowerPoint PPT Presentation

Webinar June 22, 2020 2:00-4:00PM Maine Medical Center/PIER Program An Introduction to Cognitive Behavioral Therapy for Psychosis (CBTP) Rebecca Jaynes, LCPC Sarah Lynch, LCSW Meredith Charney, Ph.D Cori Cather, Ph.D

Workshop Agenda 1. Why CBTp? 2. CBTp- Phase 1- Engagement & Introducing the model 3. CBTp-Phase 2- Assessment and Goal-Setting 4. CBTp- Phase 3- Approaching problems through: 1. Coping Skill Enhancement 2. Cognitive Restructuring (CR) *Case Example and Trainer demonstration at each phase of treatment

Poll ● Do you currently work with clients with psychosis? ● Do you use a form of CBT in your practice? • CBT for depression/anxiety • Trauma-focused CBT • Mindfulness-based CBT • CBT for psychosis

Why CBTp? ● People with psychosis want to and can play an active role in their treatment ● Many people with psychotic disorders continue to have psychotic symptoms and specific interventions to target these symptoms are warranted ● CBTp improves psychotic symptoms and decreases distress

Research supports CBTp ● Evidence base for CBTp is statistically stable and sufficient ● CBTp particularly effective for hallucinations ● Meta-analyses have also shown small to medium effects on delusions, general and negative symptoms

Meta Analysis of RCTs Comparing Efficacy of CBTp to Control Treatment on Hallucinations and Delusions (N = 2407) vs. TAU-- 0.7 hallucinations vs. TAU-- 0.6 delusions vs. AC-- 0.5 hallucinations Effect size (g) vs. AC- 0.37 0.4 0.34 0.34 delusions 0.3 0.23 0.2 0.1 0 TAU = treatment as usual; AC = active control (Turner, SZ Bull, 2020)

Who Does the Research Apply to? ● Participants who are willing and able to give informed consent ● Most studies conducted with outpatients ● Most are help-seeking ● Participants have residual distressing psychotic symptoms despite some treatment with antipsychotic medication

Overarching Goals of CBTp ● Foster a curious attitude about symptoms ● Decrease distress associated with symptoms ● Adopt “living with illness” strategy ● Improve sense of personal control ● Enhance healthy, effective coping with symptoms ● Improve day-to-day functioning ● Prevent relapse

Treatment Phases of CBTp ● Phase 1: Engagement and Intro to CBT ● Phase 2: Assessment and Goal Setting ● Phase 3: Approaching problems on the problem list ● Phase 4: Generalization of Skills and Progress Tracking ● Phase 5: Relapse Prevention

Session Structure of CBTp ● Set agenda together ● Homework review ● Symptom/functioning check ● Introduce and practice new skill ● Psychoeducation ● Collaborative homework assignment (Be prepared with handouts, write everything down, keep agenda manageable)

Case Example: Elizah • 19 year-old female, Caucasian, visual artist, creative • Referral symptoms – Longstanding visual hallucinations, recent auditory hallucinations, delusional thoughts, SI/HI • Functional difficulties – Not working or in school

Phase 1: Engagement and Intro to CBTp ● Therapeutic alliance ● Introduction to CBTp ● Teach Cognitive Model ● Examine how you think about a situation ● How you act based on your thoughts ● How your thinking and behavior together affect how you feel ● Normalization and Psychoeducation

Phase 1: Creating a Therapeutic Alliance ● Convey specific expertise and hope related to recovery from psychosis ● Empathize with distress and do not collude with delusional beliefs ● Encourage client to share paranoid beliefs about you ● Normalize and destigmatize psychosis

Trainer Demonstration – ● Session Structure, Introducing CBTp (brief)

Phase 2: Assessment and Goal Setting ● Assessments and measures to establish baseline and track progress ● Case Formulation – Begin “Making Sense” (Active process documented over time – puts current concerns in context of person’s history, strengths, stressors, thought/feeling/behavior patterns) ● Develop Problem and Goal List

Evolution of Elizah’s Delusion “I’ve always been creative. I’d see creatures in the closet and in corners as long as I can remember…I just thought everyone did.” “Earlier this year, my grandmother died. I started having nightmares about her dying. I was depressed , my art got dark, and I started seeing these spirits from the nightmares. I’d see them everywhere, they’d talk to me, tell me I was evil too. Everything was falling apart, I stopped sleeping because of the nightmares and voices and spirits. I realized then that this evil in my dreams was in me. I was the evil one, and I must have caused her death ” “And then my girlfriend broke up with me, I was so hurt. The evil voice took over and made me threaten to kill her …then I got so scared. I thought, “I could have killed her too” So I hid away in my room, to keep everyone safe. “I have an evil spirit in me” “I am dangerous to others”.

Formulation of Elizah’s Difficulties Thoughts: “I am Situation: Voices: dangerous” “You caused 1) GM death Feelings: her to die” 2) Break up Scared, “She deserves with girlfriend powerless, lonely to die too” Behaviors: stay “Kill her” in my room to keep others safe Underlying Concerns/Core Beliefs: “I’m evil inside” I’m dangerous to other people” Functional Challenges: Can’t be around people ฀ unable to work, go to school, be in public

Case Formulation

“Making Sense” ● Living document — added to over time ● Provides a platform for education about role of trauma and stress vulnerability model ● Depending on client, could share a pared down or full version ● Some clients will have making sense as a goal; others will respond to this as a way of figuring out how to individualize CBT to their particular life situation

Making Sense Predisposing factors Precipitating factors Perpetuating factors Protective factors Current concerns FEELINGS ACTIONS THOUGHTS PHYSICAL SOCIAL - UNDERLYING CONCERNS Courtesy of Dr. David Kingdon

“Making Sense” Components “The 4 P’s” Predisposing: vulnerabilities such as genetic/biological/familial factors; childhood trauma Precipitating: factors occurring right before the episode: increased stress, drug use, trauma, life change Perpetuating: factors that maintain the symptoms & problems: substance use, safety behaviors, family issues Protective: positive traits/behaviors or resilience factors: medication adherence, family support, personality factors

“Making Sense” Components (cont’d) Current Concerns: client’s own words; tie to problem/goal list eventually Thoughts/Feelings/Actions: typical, frequent patterns related to symptoms and other problems (“The voices are going to harm me”/Scared/Close curtains and stay in all day) Social/Physical: perceived challenges; can be beliefs or specific symptoms/concerns/problems Underlying Concerns: the heart of client’s negative affect; core beliefs about self, others, and world that perpetuate psychotic and other symptoms

Trainer Demonstration: Making Sense

Making Sense-Elizah Protective factors Predisposing factors Precipitating factors Perpetuating factors --Doing things that make --Longstanding --Death/breakup --Feeling weak, alone me feel strong (selling art, illusions/hallucinations --Loss/rejection --Not asking for help posting online, speaking --Creative/visual --Feeling out of control --Too much art to cope out) --Isolated --Depression --Isolating -- Don’t ask for help --Asking people I love for --Fear of intimacy --Engaging with the voices help --Limited coping skills --Not seeing myself as crazy Current concerns 1) Am I evil? 2)Am I safe/in control? 3)Am I capable of working/being in a relationship (safely)? THOUGHTS FEELINGS ACTIONS “I’m evil inside” --Scared -- Stay home (isolate) -- ”Disconnect” --Powerless “I am dangerous to others” --Incapable --Isolate --Lonely --Hurt myself to make the voice stop SOCIAL PHYSICAL --No friends --Feel unhealthy --Avoids interactions, even with family UNDERLYING CONCERNS/ CORE BELIEFS “I’m weak.” “I’m flawed/something is wrong with me.” “I am a bad person.” I’m crazy/out of control” “I can’t trust myself” Courtesy of Dr. David Kingdon

Phase 2 Continued: Developing A Problem List And Goals

Develop a Problem/Goal List ● Collaboration is key ● Use client’s own words ● Assess what is most important to guide goal development ● Prioritize and maintain focus on function ● Include at least one goal related to a psychotic symptom

Elizah’s Problem List Identified areas of concern: 1. I want to keep others safe from the evil. 2. I want to keep the evil under control. 3. I want to be able to do things again, like work. Goals: 1. Learn ways to keep myself and others safe. 2. Learn ways to feel more in control of my emotions and behaviors. 3. Learn ways to live with difficult experiences, to become more independent (get a job).

Ongoing Assessment