Psychosis 2Dr Mike RennoldsonI-WHO, University of NottinghamDerbyshire Mental Health Services NHS Trust

© Institute of Work, Health and Organisations, University of Nottingham (2009)

Learning outcomes – session 2 Knowledge of three psychological interventions for

psychosis Knowledge of how services are delivered for people

with psychosis

Re-visiting last week In pairs or threes, share what you can remember from

last week’s lecture about:- What is psychosis?- How are people’s lives affected by psychosis?- What theories explain the cause and persistence of

psychosis?

(2-3 minutes)

Key debates – a reminder Is psychosis best considered within a categorical

‘disease’ model, or as a continuum Can we integrate into a single theory the social,

psychological and biological factors that areimplicated in the causation of psychosis?

Untangling cause and effect in chronic illness.

The service context Psychosis as ‘major mental illness’ Mental Health Act Aggressive Community Treatment- Assertive Outreach Teams- Early Intervention in Psychosis Teams Hegemony of biological psychiatry

Intervention 1 - CBT Aim: to reduce ‘positive’

symptoms and ensuingdistress / poorfunctioning

For: people with residualsymptoms after anti-psychotic treatment

Biased reasoning processes Jumping to conclusions Data gathering bias Externalizing attributional

style Poor social understanding

Dysfunctional schemas Poor self-concept Low self-esteem

Cognitive-behavioural theory

Event (Meaning)

Behaviour

Emotion

Learning

An overview of CBTKey principles Structured Time-limited Focussed upon specific

goals Transparent ‘Collaborative

empiricism’ (2 experts)

Key processes1. Engagement2.Assessment3. Formulation4.The contract5. Interventions6.Relapse prevention

CBT for psychosis: 3 strands1. Modifying cognitions relating to hallucinations or

delusions.2. Coping strategy enhancement (especially for

auditory hallucinations)3. Modifying cognitions not specific to psychosis (self-

appraisal, anxiety etc)

CBT - problems Initial engagement Conviction in belief Encouraging talk about symptoms Time limitations Other interventions Emotional difficulties Other factors affect symptoms Maintenance

CBT – effectiveness research Jones et al 2004 (Cochrane review) (& Lynch et al, 2009)

30 papers, 19 trials CBT compared to usual care

No reduction in relapse and readmission Decreased risk staying in hospital Improved mental state in medium term but not after a

year No effect on measures of mental state

CBT compared to supportive Psychotherapy → nosig differences

Evidence not conclusive More trials justified

Effect Size

0 10

Improvement overtime

Control

X Participant in treatmentconditionX Participant in control condition

Control mean Treatmentmean

x x xxxxxxx

Treatment

Treatment

x x x x

x x x x xx

x x xx xx x x xx

Control xxxxxx x xxx

Control mean Treatmentmean

Effect sizeCohen’s d = difference between group means

within group variation (s.d.)- The unit of measurement is not required in effect size.- Meta-analyses calculate the average effect size across

many comparative treatment studies, taking intoaccount the sample size of each study.

Exercise: Formulation Generate a client In twos or threes, identify what cognitive or

behavioural processes may be maintaining theproblem

1. Event 2. Meaning 3. Emotion& behaviour

4. Outcome

Intervention 2 – Family work Aim: to reduce high

levels of expressedemotion

For: people with high

relapse rate families with signs of

high EE

The Five Constructs of EE Criticism Emotional ‘over-

involvement’ Hostility Warmth Positive remarks

Family Work - relationship

Two therapists Advice giving Collaborative partnership working Warmth & genuineness necessary but not sufficient Delivered in the home, family members can be seen

separately Education sometimes delivered in relatives groups

Family Work - components Education programme Developing good communication Problem solving Encouraging good ‘CBT’ coping skills Re-framing criticism Working with guilt Changing roles

Family Work - Effectiveness research(Pilling et al, 2002)

Over 30 RCTs More effective than any comparator at reducing

relapse and readmission over two years. Lower rates of disengagement than for comparator

treatments. NICE guideline (2009) - 10 sessions over 3 months -

1 year.

Key debates 2 Is psychosis best considered within a categorical

‘disease’ model, or as a continuum Can we integrate into a single theory the social,

psychological and biological factors that areimplicated in the causation of psychosis?

Untangling cause and effect in chronic illness.

Intervention 3: cognitiveremediation therapy Aim: to improve deficits

in cognitive functioning For: people with

‘negative’ symptoms andpoor social functioning

Cognitive flexibility Working memory Planning

Cognitive remediation therapy Intensive, frequent, training programme using

‘errorless learning’. Wykes et al (2007) found improvements in working

memory and social functioning

Intervention 4 – Hearing VoicesMovement & Social RevoveryHearing Voices Groups Accept eachother’s experiences as real, rather than

merely ‘symptoms’ Communicate with the voices, to change their

relationship with them Meet others with similar experiences

Social recovery - what are peoplerecovering from?

People may be experiencing difficulties from: Distress and trauma of the psychotic experiences Social exclusion Discrimination Stigma Loss of position in society Messages of hopelessness Possible forced hospitalisation Medication Devaluing and disempowering services Trauma of receiving a diagnosis

RefsC, Cormac I, Silveira da Mota Neto JI, Campbell C. Cognitive behaviour therapy for schizophrenia.

Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No.: CD000524. DOI:10.1002/14651858.CD000524.pub2

Lynch, D., Laws, K., & McKenna, P. (2009) Cognitive behavioural therapy for major psychiatric disorder:does it really work? A meta-analytical review of well-controlled trials. Psychological Medicine

NICE. (2009). Core interventions in the treatment and management of schizophrenia in primary andsecondary care (update)

http://www.nice.org.uk/guidance/index.jsp?action=byID&o=11786

Pilling, S., Bebbington, P., Kuipers, E., Garety, P., Geddes, J., Orbach, G., & Morgan, C. (2002).Psychological treatments in Schizophremina: I. Meta-analysis of family intervention and cognitivebehaviour therapy. Psychological Medicine, 32, 763-783..

Wykes, T., Reeder, C., Landau, S., Everitt, B., Knapp, M., Patel, A., & Romeo, R. (2007). Cognitiveremediation therapy in schizophrenia. British Journal of Psychiatry 190: 421-427