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Cognitive Therapy for Cognitive Therapy for PsychosisPsychosis
An Individualized Approach for An Individualized Approach for “Extreme States”“Extreme States”
Presenter: Ron Unger LCSWPresenter: Ron Unger LCSW
541-513-1811541-513-1811
[email protected]@gmail.com
The Essential idea of Cognitive-The Essential idea of Cognitive-Behavioral Therapy:Behavioral Therapy:
If you learn to think and act differently, then If you learn to think and act differently, then your mental and emotional problems may your mental and emotional problems may disappeardisappear
You can learn to take responsibility for You can learn to take responsibility for changing your thoughts and behaviorschanging your thoughts and behaviors though you may need others to help you figure though you may need others to help you figure
out how to do itout how to do it
From an “Illness Management & From an “Illness Management & Recovery” workbookRecovery” workbook
““What causes schizophrenia?What causes schizophrenia? ““Schizophrenia is nobody’s fault. This means Schizophrenia is nobody’s fault. This means
that you did not cause the disorder, and that you did not cause the disorder, and neither did your family members or anyone neither did your family members or anyone else. Scientists believe that the symptoms of else. Scientists believe that the symptoms of schizophrenia are caused by a chemical schizophrenia are caused by a chemical imbalance in the brain.”imbalance in the brain.”
P. 177 of workbook at http://www.ncebpcenter.org/pdfs/wmrdox/wmr.handouts.pdf
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 how to anticipate it, but with effort and with help you may learn to get out of it”
The extreme version of the “Medical Model” tries to relieve The extreme version of the “Medical Model” tries to relieve shame & blame, but it goes too far:shame & blame, but it goes too far:
Cognitive therapy for psychosisCognitive therapy for psychosis
Is a systematic approachIs a systematic approach With published therapy manualsWith published therapy manuals
• Though treatment requires an individualized Though treatment requires an individualized approach, more so than in other varieties of approach, more so than in other varieties of cognitive therapy cognitive therapy
Is well researchedIs well researched At least 36 randomized studiesAt least 36 randomized studies
• Showing significant effects on averageShowing significant effects on average (Beck, 2009)(Beck, 2009)
Is recognized as an “evidence based practice”Is recognized as an “evidence based practice”
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 smaller study showed cognitive therapy One smaller study showed cognitive therapy was helpful for clients who chose not to use was helpful for clients who chose not to use medication (a larger study is now underway.)medication (a larger study is now underway.)
A. P. Morrison, 2011A. P. Morrison, 2011
Graph as printed in “Anatomy of an Epidemic” by Robert Whitaker
Definition of “psychosis”Definition of “psychosis”
"A severe mental disorder, with or "A severe mental disorder, with or without organic damage, characterized without organic damage, characterized by derangement of personality and loss by derangement of personality and loss of contact with reality and causing of contact with reality and causing deterioration of normal social deterioration of normal social functioning.“functioning.“
From the American Heritage Stedman Medical Dictionary From the American Heritage Stedman Medical Dictionary
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
Isolation as contributing cause to psychosis: see http://isps-us.org/koehler/sociocultural.htm
Dialogue and the Edge Dialogue and the Edge between Balance and between Balance and
ImbalanceImbalance Rationality emerges out of dialogueRationality emerges out of dialogue
Not by suppressing "irrational" viewsNot by suppressing "irrational" views Health is not the absence of disruptive Health is not the absence of disruptive
emotions and thoughtsemotions and thoughts But rather a meta-balance between But rather a meta-balance between
what is disruptive and what is what is disruptive and what is stabilizingstabilizing
Fusion:
My emotions or thoughts take over, or 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.
Experiential Avoidance:
I reject my feelings or thoughts, or see them as my enemy:
I need to block them out (or drugthem away)
Mindful Dialogue:
I include all of my emotions & the thoughts associated with them in an ongoing internal dialogue.
Decisions about what to do emerge from this process.
Two extremes, when rational internal dialog is missing:
One thing that can disrupt internal One thing that can disrupt internal dialog: Traumadialog: Trauma
When arousal is too great, parts of the mind that When arousal is too great, parts of the mind that generate internal dialog evaluating danger can generate internal dialog evaluating danger can shut down shut down (van der Kolk, 2006)(van der Kolk, 2006)
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” – (John Read, 2008)– (John Read, 2008)
The good and bad of trauma-The good and bad of trauma-inspired monological thinkinginspired monological thinking
Fusion with one point of view, avoidance of Fusion with one point of view, avoidance of other views, makes for a strong decision and other views, makes for a strong decision and determined action in a crisisdetermined action in a crisis But it interferes with ability to understand others But it interferes with ability to understand others
and other possibilitiesand other possibilities If one firmly decides something, but it doesn’t If one firmly decides something, but it doesn’t
work, one might “flip” to a different firmly held work, one might “flip” to a different firmly held viewview Black and white thinking, one view state Black and white thinking, one view state
dissociated from the otherdissociated from the other
The Healthy Meta-BalanceThe Healthy Meta-Balance
A healthy dialogue A healthy dialogue Then shifting from dialogue to a Then shifting from dialogue to a
decision decision A decision that emerges out of the A decision that emerges out of the
dialoguedialogue Reopening the dialogue after a decision Reopening the dialogue after a decision
is made is made So behavior is informed by feedbackSo behavior is informed by feedback
What is most essential to What is most essential to CBT for Psychosis:CBT for Psychosis:
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
From the book “Cognitive Therapy of Schizophrenia” by Kingdon & Turkington, p 43
Another fundamental ingredient: Another fundamental ingredient: HopeHope
Modern finding: that mental activity can Modern finding: that mental activity can change biochemistry and eventually brain change biochemistry and eventually brain structurestructure This finding is known as “neuroplasticity” This finding is known as “neuroplasticity” A reason for hopeA reason for hope
Not really more mystical than the notion Not really more mystical than the notion that bodily activity can change the body, that bodily activity can change the body, i.e., exercise changes muscles, etc.i.e., exercise changes muscles, etc.
Goals structured around what client wants Goals structured around what client wants Collaborative EmpiricismCollaborative Empiricism Middle ground between confrontation and Middle ground between confrontation and
collusioncollusion Socratic DialogueSocratic Dialogue Avoiding the role of “expert”Avoiding the role of “expert” Curiosity about client’s efforts to make senseCuriosity about client’s efforts to make sense
EmpathyEmpathy Self disclosureSelf disclosure
Elements of the Cognitive Elements of the Cognitive ApproachApproach
Therapy by formula:
I just do what is in the therapy manual, whether it works or makes sense to the individual client or not. I always know exactly what I am doing though.
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.
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.
CBT for psychosis includes “off the map” exploration:
ExerciseExercise
““Client” chooses a controversial or even Client” chooses a controversial or even “psychotic” belief“psychotic” belief
““Therapist” engages in discussion using Therapist” engages in discussion using “collaborative empiricism”“collaborative empiricism” Avoid confrontation or collusionAvoid confrontation or collusion First, briefly explore why “client” believes itFirst, briefly explore why “client” believes it Then, gently draw out from the “client” any Then, gently draw out from the “client” any
possible reasons to doubt that the belief is possible reasons to doubt that the belief is completely truecompletely true
Remember, Relationship First!Remember, Relationship First!
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 On a continuum with, even if more extreme On a continuum with, even if more extreme
than, everyday sorts of troublesome than, everyday sorts of troublesome experiences and confusionexperiences and confusion
NOT exotic “symptoms” imposed on the NOT exotic “symptoms” imposed on the personalitypersonality
Normalizing reduces the panic and Normalizing reduces the panic and emotional arousal that often leads to more emotional arousal that often leads to more symptomssymptoms
From the book “Cognitive Therapy of Schizophrenia” by Kingdon & Turkington, p 83-05
DIALECTICAL BEHAVIOUR THERAPY: DIALECTICAL BEHAVIOUR THERAPY: Linehan’s STATES OF MIND applied to Linehan’s STATES OF MIND applied to
PSYCHOSISPSYCHOSIS
reasonable mind
Ordinary thinking
Shared reality.
wiseMind –in touch With both
in the presentin control
emotion mind
or open to other ways
of experiencing
Non-shared reality
Shared and Non-shared Reality
Slide by Isabel Clarke and Donna Rutherford
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
Stress
Accepting the voices and taking action to reduce stress results in less stress over time, & less preoccupation with voices
Interpret voice as an effect of stress
Hearing a voice
Accept the voice as a signal of stress, take action to reduce the stress
Stress
NormalizingNormalizing
Uses the notion of experiences existing on Uses the notion of experiences existing on a continuuma continuum Even if “tipping points” do sometimes existEven if “tipping points” do sometimes exist
Avoids language that exaggerates Avoids language that exaggerates differencesdifferences
Makes recovery appear more achievableMakes recovery appear more achievable By recognizing that being healthy still means By recognizing that being healthy still means
having “issues”having “issues”• Just managing them a bit betterJust managing them a bit better
That which one
consciously identifies
with
Impulse
Emotion
“Inner” Voice
Thought
External World
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.
Memories
Spontaneous imagination
That which one
consciously identifies
with
Evil Spirits
Aliens
Witchcraft
Brain Implant
External World
Satan
Examples of interpretations of inner experiences as being sourced in something other than the self
TelepathyVoice that isn’t part of me…
That which one
consciously identifies
with
Mental Illness
Chemical Imbalance
External World
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”
Misfiring synapses
“Symptoms”
Developing a formulationDeveloping a formulation
A formulation is a hypothesis or story A formulation is a hypothesis or story aboutabout what caused problems to develop, and what caused problems to develop, and what maintains the problemswhat maintains the problems
The formulation providesThe formulation provides hope that the problem can be overcome, hope that the problem can be overcome, as well as suggestions about how to do thatas well as suggestions about how to do that
What’s causing 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?
Therapist: We can diagnose you with the illness called schizophrenia because you have these weird experiences.
Problems occur when a “diagnosis” is used as an explanation for the problem
From “Madness Explained” by Richard Bentall
The traditional explanation is linear and offers little hope for recovery
Biology
Person’s mental activity and behavior
Social/
environmental
Biological Psychological Social etc.
Mostly Biological Model of Causality in “Mental Illness” Popular Today
Biology
Person’s mental activity and behavior
Social/
environmental
Biological Psychological Social etc.
A Truly Bio-Psycho-Social Model of Causality in “Mental Illness”
From: A Casebook of Cognitive Therapy for Psychosis, Edited by Anthony P. Morrison
Being hurt in the past,
betrayed by friends
Want to make sure it doesn’t happen again
Get very attentive to possible clues betrayal could be
happening, “paranoia makes
me safe”
See betrayal as happening at
times even when it likely isn’t
Friends see you as paranoid, turn
against you, more betrayal
Try even harder to make sure
betrayal doesn’t happen again
Accuse friends of betrayal
Paranoia escalates
A key thing to look for in a A key thing to look for in a formulation:formulation:
When efforts to make things better are When efforts to make things better are inadvertently making it worseinadvertently making it worse As things get worse, misguided efforts to As things get worse, misguided efforts to
make them better often intensifymake them better often intensify• Leading to things getting even worseLeading to things getting even worse
Without insight into the vicious circle, it just Without insight into the vicious circle, it just acceleratesaccelerates Or is perceived to be a result of a “biologically Or is perceived to be a result of a “biologically
based mental illness”based mental illness”
(Gumley, Braehler, Laithwaite, MacBeth, & Gilbert, 2010)
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
Conflict or problem that
seems beyond person’s ability
to manage
Experimentation beyond usual
limits in an attempt to resolve the
conflict
Attempts at solutions that
come out of this process cause problems for self or others
Conflict emerges between part of
self that wants to return to usual limits, and part that wants to
continue experimentation in
attempt to solve original conflict
Conflict that now seems even more beyond person’s ability to manage
More problems, etc, until or unless conflicts and
problems start to be resolved, due to help and/or person’s own
success.
Further experimentation/
experiences beyond usual
limits
“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
A less extreme story leaves more room for growth & development
Definition of “Paranoia”Definition of “Paranoia”
A psychotic disorder characterized by A psychotic disorder characterized by systematized delusions, especially of systematized delusions, especially of persecution or grandeur, in the absence of persecution or grandeur, in the absence of other personality disorders. other personality disorders.
Extreme, irrational distrust of others. Extreme, irrational distrust of others. From The American Heritage® Stedman's Medical Dictionary From The American Heritage® Stedman's Medical Dictionary
(Note that any kind of interpersonal (Note that any kind of interpersonal anxiety is on a continuum with “paranoia”)anxiety is on a continuum with “paranoia”)
Normalizing: Understanding the Normalizing: Understanding the Possible Roles of ParanoiaPossible Roles of Paranoia
Helps us detect threatsHelps us detect threats Can make us feel saferCan make us feel safer
• ““they won’t slip anything past me”they won’t slip anything past me”
Gives us someone else to blameGives us someone else to blame ““I’m very competent, but there’s trouble I’m very competent, but there’s trouble
because all these people are against me”because all these people are against me”
When paranoia is protecting self When paranoia is protecting self esteem:esteem:
Then directly challenging paranoid beliefs Then directly challenging paranoid beliefs may threaten self esteemmay threaten self esteem So first develop alternative ways to protect a So first develop alternative ways to protect a
sense of self worthsense of self worth• then can realistically look at evidence for and then can realistically look at evidence for and
against paranoid viewsagainst paranoid views
From Cognitive Neuropsychiatric Models of Persecutory Delusions Nigel J. Blackwood, M.A., M.R.C.Psych., Robert J. Howard, M.D., M.R.C.Psych., Richard P. Bentall, Ph.D. and Robin M. Murray, F.R.C.Psych., D.Sc. Am J Psychiatry 158:527-539, April 2001 © 2001
Vigilance-Avoidance: Vigilance-Avoidance: A source of paranoiaA source of paranoia
People prone to paranoia tended to look People prone to paranoia tended to look away from threatening stimuli sooner than did away from threatening stimuli sooner than did non-paranoid peoplenon-paranoid people But then they tended to perceive more threat But then they tended to perceive more threat
coming from stimuli others saw as neutralcoming from stimuli others saw as neutral
The “looking away” can be seen as a form of The “looking away” can be seen as a form of avoidance, meant to lower emotional arousalavoidance, meant to lower emotional arousal But it causes new problems when neutral stimuli But it causes new problems when neutral stimuli
then appear threatening & trigger more arousalthen appear threatening & trigger more arousal
Green & Phillips, 2004 Social Threat Perception and the Evolution of Paranoia
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 A couple ways CBT looks at “delusions” differently“delusions” differently
People may claim 100% certainty, and People may claim 100% certainty, and seem to ignore evidence, seem to ignore evidence, but when encouraged to be thoughtful, they but when encouraged to be thoughtful, they
often change beliefs at least somewhatoften change beliefs at least somewhat There may be a grain of truth (or There may be a grain of truth (or
sometimes much more) in apparently sometimes much more) in apparently delusional beliefsdelusional beliefs Or a belief may be metaphorically true, even Or a belief may be metaphorically true, even
though literally falsethough literally false
Four ways of working with probable Four ways of working with probable delusions:delusions:
1. Find out how the person came to have the 1. Find out how the person came to have the belief, including life events preceding its belief, including life events preceding its developmentdevelopment
2. Help the person expand engagement with the 2. Help the person expand engagement with the world and with other peopleworld and with other people
3. Explore & help person learn to relate 3. Explore & help person learn to relate differently to underlying vulnerabilitiesdifferently to underlying vulnerabilities
4. Evaluate the belief by4. Evaluate the belief by• exploring evidence for and againstexploring evidence for and against• developing self-esteem preserving alternativesdeveloping self-esteem preserving alternatives• testing beliefstesting beliefs
Getting started: Exploring Getting started: Exploring what’s positive about the beliefwhat’s positive about the belief
It may explain certain evidence that It may explain certain evidence that otherwisotherwisee lacks explanation lacks explanation
The person may gain certain advantages The person may gain certain advantages by believing itby believing it
The belief may be a metaphor for The belief may be a metaphor for something the person is not able to something the person is not able to describe or relate to more directlydescribe or relate to more directly Literally untrue, but true in some senseLiterally untrue, but true in some sense
Exploring a Belief, Without Confronting Exploring a Belief, Without Confronting or Colluding:or Colluding:
Suspend your disbelief: stay in “maybe”Suspend your disbelief: stay in “maybe” Go slow, be diplomaticGo slow, be diplomatic Frame the belief as one way of making Frame the belief as one way of making
sense of specific experiencessense of specific experiences Acknowledge and honor evidence that Acknowledge and honor evidence that
supports the beliefsupports the belief Be curious about how other possibilities Be curious about how other possibilities
were ruled outwere ruled out
Helping people become open-Helping people become open-minded about beliefsminded about beliefs
List advantages & disadvantages of the List advantages & disadvantages of the beliefbelief
Discover alternative ways of Discover alternative ways of accomplishing the purposes of the belief, accomplishing the purposes of the belief, or of overcoming the disadvantages of the or of overcoming the disadvantages of the
beliefbelief Look carefully at evidence for the belief Look carefully at evidence for the belief
and at other perspectives and at other perspectives Help person anticipate how to forgive self Help person anticipate how to forgive self
if it turns out a view was mistakenif it turns out a view was mistaken
When you are ready to weigh the When you are ready to weigh the evidence:evidence:
Be curious about details and Be curious about details and inconsistenciesinconsistencies
Ask what was most puzzling about Ask what was most puzzling about experiences that led to the beliefexperiences that led to the belief
Notice “safety behaviors” that may be Notice “safety behaviors” that may be impeding collection of disconfirming impeding collection of disconfirming evidenceevidence
Find ways to gather more dataFind ways to gather more data
Psychotic experience and Psychotic experience and spirituality:spirituality:
The presence of some distressisng “psychotic” The presence of some distressisng “psychotic” experience does not mean the person cannot experience does not mean the person cannot also have helpful spiritual experiences (often also have helpful spiritual experiences (often mixed together.)mixed together.)
What the therapist can doWhat the therapist can do Help person distinguish helpful from unhelpful Help person distinguish helpful from unhelpful
experiences and interpretationsexperiences and interpretations• Being curious about times of possibly “mind too open” and/or Being curious about times of possibly “mind too open” and/or
of “mind too closed”of “mind too closed”
Exploring inconsistencies with the person’s Exploring inconsistencies with the person’s own spiritual traditions can be one way of own spiritual traditions can be one way of helping the person see additional optionshelping the person see additional options
HallucinationsHallucinations
Cognitive therapists see these as just a Cognitive therapists see these as just a person’s own thoughts or imaginings person’s own thoughts or imaginings about something in the world, about something in the world,
temporarily mistaken for perceptions coming temporarily mistaken for perceptions coming in directly from the external worldin directly from the external world
• See See Cognitive Therapy for Schizophrenia” Kingdon & Turkington, p 22
Different in style – “dreaming while Different in style – “dreaming while awake”awake”
The goal of cognitive work with The goal of cognitive work with voices & other hallucinations:voices & other hallucinations:
NOT to eliminate voices or NOT to eliminate voices or hallucinations hallucinations anymore than the goal of cognitive work anymore than the goal of cognitive work
with panic is to eliminate the body with panic is to eliminate the body sensations that are often misinterpreted as sensations that are often misinterpreted as something elsesomething else
Rather Rather the focus is on changing beliefs and the focus is on changing beliefs and
associated behaviors around the voices or associated behaviors around the voices or other hallucinationsother hallucinations• in a way that reduces distress & enhances in a way that reduces distress & enhances
integrationintegration
See “Cognitive Therapy for Psychos: A Formulation-Based Approach” by Morrison et al, p 37-38
33rdrd Wave of CBT: Wave of CBT:Not about “getting rid of” the symptomNot about “getting rid of” the symptom
Instead, change relationship to itInstead, change relationship to it
Problematic relationships with thoughts, Problematic relationships with thoughts, voices, feelings etc. can range fromvoices, feelings etc. can range from Inability to accept their existence, or to “sit with” Inability to accept their existence, or to “sit with”
themthem Acting on them inappropriatelyActing on them inappropriately Failing to act on them in ways that would be Failing to act on them in ways that would be
appropriateappropriate A better relationship:A better relationship:
Able to accept internal stimuli & sort out Able to accept internal stimuli & sort out appropriate actionappropriate action
Definition of an obsession, as contrasted with a hallucination:
An obsession:An obsession: Involves ideas, thoughts, or images that are
involuntarily produced (as are hallucinations) Occurs recurrently and persistently and is
experienced as senseless and repugnant (as are some hallucinations)
Usually the anxiety about having the obsession seems to increase its power, as it does for voices and other hallucinations
Is recognized as the product of one's own mind (unlike hallucinations.)
See “Cognitive Therapy of Schizophrenia” by Kingdon & Turkington, p 61
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
Confusion caused by coexistence of hypervigilance and blocking perceptions, otherwise known as “vigilance-avoidance”
Hearer of the thought
Speaker of the thought
Normal identity in our culture: we see ourselves both as who is saying or “thinking” the thought to ourselves, and as the person who is registering or hearing the thought. Our identity is not centered in either saying or hearing the thought.
Hearer of the thought:another“alter”
Speaker of the thought: an “alter”
Dissociative identity: person may have a conversation with “alternate personalities” within themselves. At any given moment, a person may see themselves as a particular personality or self sharing a body with other personalities or selves.
Hearer of the thought:Identified
“self”
Speaker of the thought: a “voice”
Hearing voices: Person sees thought as coming from outside themselves. They may be “heard” as though spoken aloud, or just heard “inside one’s head” but there is the sense or the belief that they are coming from something completely outside the self.
Health and VoicesHealth and Voices
You can actually receive a mental health You can actually receive a mental health diagnosis if you fail to hear a certain voicediagnosis if you fail to hear a certain voice (the voice of your conscience)(the voice of your conscience)
It is often useful to distinguish different It is often useful to distinguish different “voices” within our psyche for various “voices” within our psyche for various reasonsreasons The voice of our fears, our mother’s voice, The voice of our fears, our mother’s voice,
whateverwhatever
C
Bigger picture of healthy identity (or healthy internal politics):
Good judgment or good self government emerges out of tension and constructive dialogue between various internal “voices,” “parts,” or “perspectives.”
B
A
Three levels of belief about voices:
1., Beliefs about the content of what the voices say:
• is what the voices say true or not?
2., Beliefs about the power of the voices.• Are the voices more or less powerful than the
person?
3., Beliefs about the identity of the voices.
Challenging beliefs about content:Challenging beliefs about content:
This often resembles CBT work with This often resembles CBT work with automatic thoughtsautomatic thoughts (Possible difference: if content is given more (Possible difference: if content is given more
weight because of the presumed identity of weight because of the presumed identity of the voice)the voice)
People can take a very passive stance, People can take a very passive stance, believing things just because they are saidbelieving things just because they are said
Fusion:
My emotions or voices take over, or 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.
Experiential Avoidance:
I reject my feelings or voices, or see them as my enemy:
I need to block them out (or drugthem away)
Mindful Dialogue:
I include all of my emotions & any voices associated with them in an ongoing internal dialogue.
Decisions about what to do emerge from this process.
How issues with voices resemble issues with emotions….
Avoiding exposure to voice content Avoiding exposure to voice content can lead to prolonged vulnerabilitycan lead to prolonged vulnerability
When critical remarks are avoided, it is When critical remarks are avoided, it is difficult to put them into perspectivedifficult to put them into perspective Most common coping tools: medications & Most common coping tools: medications &
distractiondistraction• Both involve avoidance of voice contentBoth involve avoidance of voice content
Contrast that with the “balanced view”Contrast that with the “balanced view” This values self-critical evidence & This values self-critical evidence &
perspectives, but is not dominated by themperspectives, but is not dominated by them
Challenging Beliefs about PowerChallenging Beliefs about Power
Successful coping reduces belief in the power of Successful coping reduces belief in the power of the voicethe voice Identify methods that aren’t working or Identify methods that aren’t working or
inadvertently make the voices worseinadvertently make the voices worse• Trying too hard to “get rid” of them can make them appear to Trying too hard to “get rid” of them can make them appear to
be more powerfulbe more powerful
Examples of coping ideas:Examples of coping ideas:• Practice starting and stopping themPractice starting and stopping them• Setting limits (can role play)Setting limits (can role play)• MindfulnessMindfulness• Active ImaginationActive Imagination
Coping StrategiesCoping Strategies
No one option is best for all circumstancesNo one option is best for all circumstances Flexibility, fitting the best strategy to the Flexibility, fitting the best strategy to the
circumstance, is keycircumstance, is key A common problem is when someone A common problem is when someone
relies too much on one or two methods, relies too much on one or two methods, with little access to other methodswith little access to other methods CBT therapists call this the problem of CBT therapists call this the problem of
“overdeveloped” and “underdeveloped” “overdeveloped” and “underdeveloped” coping strategiescoping strategies.
See the book “Staying well after psychosis” by Gumley & Schwannauer, p. 193-195
Beliefs about the identity of Beliefs about the identity of voices:voices:
The most helpful beliefs are those that give the The most helpful beliefs are those that give the person a sense of power in relation to the voiceperson a sense of power in relation to the voice
It might be important to explore advantages and It might be important to explore advantages and disadvantages of certain beliefs, not just disadvantages of certain beliefs, not just evidence for and againstevidence for and against
Don’t insist on a scientific understanding: as Don’t insist on a scientific understanding: as long as the person regains his or her sense of long as the person regains his or her sense of power in relation to the voice, he or she may be power in relation to the voice, he or she may be fine.fine.
Also a factor: Beliefs about Also a factor: Beliefs about IntentionIntention
Belief voice is very positive and helpfulBelief voice is very positive and helpful Can lead to over-relianceCan lead to over-reliance
Belief voice is malevolentBelief voice is malevolent Can lead to exhaustion in fighting itCan lead to exhaustion in fighting it
• Then often giving up & submitting to it!Then often giving up & submitting to it!
A more flexible approach: the belief that a A more flexible approach: the belief that a voice may or may not be helpful in a particular voice may or may not be helpful in a particular situationsituation Keeping an open yet critical mind is more likely to Keeping an open yet critical mind is more likely to
be successfulbe successful
Understanding Thought Understanding Thought Disorder:Disorder:
Disordering thoughtDisordering thought can serve some functions, can serve some functions, such as:such as: communicating something the person cannot express communicating something the person cannot express
any other wayany other way• Such as expressing a person’s sense of overwhelm when no Such as expressing a person’s sense of overwhelm when no
ordered approach seems adequateordered approach seems adequate getting close to an emotionally charged issue, then getting close to an emotionally charged issue, then
skipping awayskipping away appearing hyper-intelligent, creative, or deliberately appearing hyper-intelligent, creative, or deliberately
frustrating someone who is trying to follow alongfrustrating someone who is trying to follow along
Key ideas for working with Key ideas for working with disorderly thinkingdisorderly thinking
Communicate your intent to understandCommunicate your intent to understand Watch for themes, non-verbal signs, ask Watch for themes, non-verbal signs, ask
for clarification where possiblefor clarification where possible Let the person see what you are Let the person see what you are
understanding & what you are confused understanding & what you are confused aboutabout
Most of all, don’t pretend to understand Most of all, don’t pretend to understand when you don’t!when you don’t!
Negative symptoms
Such things as: not showing much affect not speaking much low activity, social withdrawal not paying attention
Understood by cognitive therapists as behaviors, or absence of behavior, that the client often uses to reduce stress
“Cognitive Therapy for Schizophrenia” Kingdon & Turkington, p 140
Absence of attempts leads to failure to develop skills
High awareness of personal failures leads to not attempting much
Absence of skills makes failure more common when activities are attempted
Notices failure acutely, sees few successes to offset the failures
Cycle of “negative symptoms”
Working with negative symptoms:
Use a very low stress approach:Use a very low stress approach: Get family on board with thisGet family on board with this
But also support activity & positive But also support activity & positive structured routinesstructured routines
Nurture dreams and purposeNurture dreams and purpose Consider the possibility that medication Consider the possibility that medication
may be aggravating negative symptomsmay be aggravating negative symptoms
See the book “Cognitive Therapy of Schizophrenia” by Kingdon & Turkington, p 138-148
More attempts leads to developing skills
High awareness of successes leads to attempting more
Presence of skills makes success more common when activities are attempted
Focuses more attention on successes, even if small
Cycle of recovery from “negative symptoms”
Relapse PreventionRelapse Prevention
Watching for signs of moving toward relapse Watching for signs of moving toward relapse Such as general signs of psychological distress, Such as general signs of psychological distress,
and/or low level psychotic symptomsand/or low level psychotic symptoms
Detecting & treating warning signs is an Detecting & treating warning signs is an effective way of preventing relapseeffective way of preventing relapse
Avoid extremes in relapse preventionAvoid extremes in relapse prevention Like oversensitivity to seeing minor mental/emotional Like oversensitivity to seeing minor mental/emotional
variations as signs of imminent relapsevariations as signs of imminent relapse• This feeds anxiety which makes relapse more likely!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 3 levels of possible integration with rest of the mental health systemrest of the mental health system
1. Cognitive therapy used for medication-1. Cognitive therapy used for medication-resistant symptomsresistant symptoms
2. Cognitive therapy made available to all who 2. Cognitive therapy made available to all who have psychotic experiences, have psychotic experiences, usually alongside medications but often resulting in usually alongside medications but often resulting in
lower doses being usedlower doses being used
3. Cognitive therapy and other psychosocial 3. Cognitive therapy and other psychosocial interventions seen as primary interventions seen as primary with medications used only when psychosocial with medications used only when psychosocial
interventions prove inadequate.interventions prove inadequate.
Integrate working with the familyIntegrate working with the family
One way cognitive therapists work with One way cognitive therapists work with families differs from that of families differs from that of “psychoeducational” approaches“psychoeducational” approaches Instead of asking family not to criticize Instead of asking family not to criticize
because client is “ill” and cannot control him because client is “ill” and cannot control him or her selfor her self• Help family understand why client is acting how Help family understand why client is acting how
they are, and how criticism is currently impacting they are, and how criticism is currently impacting themthem
This may have more long term effectivenessThis 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 Relating to other professionals who may be skeptical may be skeptical
Pay attention to ways these professionals Pay attention to ways these professionals may be distressedmay be distressed And how your new ideas and methods can be And how your new ideas and methods can be
helpful in relieving that distresshelpful in relieving that distress Seek collaborative dialogueSeek collaborative dialogue
Balance between confrontation and collusionBalance between confrontation and collusion Acknowledge their points but insist on also Acknowledge their points but insist on also
attending to contradictory evidenceattending to contradictory evidence
HomeworkHomework
Why use it:Why use it: Gets client active in the therapy processGets client active in the therapy process Appears that in general cognitive therapy that Appears that in general cognitive therapy that
uses homework is 60% more effectiveuses homework is 60% more effective• (Glaser, N.M., Kazantzis, N., Deane, F.P., & Oades, L. G, 2000)(Glaser, N.M., Kazantzis, N., Deane, F.P., & Oades, L. G, 2000)
Types of homework:Types of homework: Information collectionInformation collection ExperimentsExperiments Practice new skillsPractice new skills
Homework and session structure:Homework and session structure:
Suggested session structure:Suggested session structure:
Review client’s stateReview client’s state Set the agenda with clientSet the agenda with client Reviewing homework is “almost always” nextReviewing homework is “almost always” next Work on the agenda itemsWork on the agenda items Agree on homework for next timeAgree on homework for next time Elicit feedback about the sessionElicit 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 7 golden rules of homework compliancecompliance
Decide on work to be done jointlyDecide on work to be done jointly Clearly identify the rationale for doing itClearly identify the rationale for doing it Check out obstaclesCheck out obstacles Make it meaningful but achievableMake it meaningful but achievable Establish promptsEstablish prompts Begin use of homework in first sessionBegin use of homework in first session If it doesn’t get done, explore why, and do If it doesn’t get done, explore why, and do
it during the session if possibleit during the session if possible
See the book “Cognitive Therapy for Psychos: A Formulation-Based Approach” by Morrison et al, p 117-118
Your personal plan to implement Your personal plan to implement ideas from this seminarideas from this seminar
What things do you want to try doing differently in the What things do you want to try doing differently in the next few weeks?next few weeks?
What is your plan to keep your progress going in the What is your plan to keep your progress going in the next few months?next few months?
You can use some of the 7 rules in making these You can use some of the 7 rules in making these
plans…..plans….. Clearly identify the rationale for your planClearly identify the rationale for your plan Check out obstaclesCheck out obstacles Make your plan meaningful but achievableMake your plan meaningful but achievable Establish promptsEstablish prompts Begin right awayBegin right away If it doesn’t get done, explore why, and then start doing it ASAPIf it doesn’t get done, explore why, and then start doing it ASAP
SummarySummary Think of psychotic states as likely to have roots in normal Think of psychotic states as likely to have roots in normal
human concernshuman concerns
Join with the client, around exploring what might relieve Join with the client, around exploring what might relieve distressdistress
Suspend your disbelief, instead joining in a collaborative Suspend your disbelief, instead joining in a collaborative empirical exploration with the client, drawing out the client's empirical exploration with the client, drawing out the client's own rational process.own rational process.
Work out with the client an alternative way of making sense Work out with the client an alternative way of making sense of his or her experience, with consequences that are less of his or her experience, with consequences that are less distressing.distressing.
And do this while avoiding "cultural imperialism:" And do this while avoiding "cultural imperialism:" in other words, be open to the idea that any proposed alternatives, in other words, be open to the idea that any proposed alternatives,
like the clients own original formulation, may be only partially correct like the clients own original formulation, may be only partially correct or helpful.or helpful.
