An Introduction to a Formulation Based Approach to CBT for Psychosis 16th September 2010

1. An Introduction to a Formulation Based Approach to CBT for Psychosis16th September 2010 Dr Craig Steel Charlie Waller Institute of Evidence Based Psychological Treatment University of Reading

2. OutlineThe presentation of psychosisThe aim of CBT for psychosisDelusions and hallucinationsA cognitive model of the positive symptoms of psychosisDeveloping a formulationUsing a formulation in clinical practice The evidence base of CBTpThe relationship between trauma and psychosis

3. Symptoms of Psychosis Issues of Diagnosis – Schizophrenia Positive Symptoms Hallucinations Delusional beliefs / Paranoia Disordered thoughts Negative Symptoms Focus on positive symptoms Paranoia and Voices across disorders

4. Video Clips Implications for Therapy Being ‘stuck’ in a seemingly irrational belief Need a different way of approaching the topic Chaotic & distressing experiences Are they random?

5. How should CBT work Client defined goals Collaborative approach, therapist not the expert The clients view is one possible explanation A formulation helps make sense of a range of problems Formulation is not fact, it allows the client flexibility to check things out

6. What is aim of CBT for Psychosis ?This Workshop Where Possible: A formulation based approach to help someone understand why they have these distressing experiences or ‘symptoms’ As ever in CBT, the intervention evolves from the formulation To build upon what you already know about CBT for anxiety and depression

7. LET’S BE REALISTIC Engagement difficulties Cognitive difficulties and motivation The evidence base

8. LET’S BE REALISTIC, BUT A seemingly small change can be extremely important

9. Cross sectional formulations

10. Generic Cognitive Model

11. BIG ISSUE When do I need to use a cross-sectional formulation and when do I need to use a longitudinal one?

12. Level of formulation Severity of the problem Keep therapy as SIMPLE AS POSSIBLE to achieve goals Probably won’t know to start with Inclusion of core belief in a formulation doesn’t mean it becomes a target Example: the four ways in which psychological life are conventionally catagorised reflect the internal workings and psychological state of a person at a particular point in time For instance changing ones perspective can provide a new outlook that helps dissipate stress, reduce tension, and encourage constructive activity Meanwhile person is interacting with the external world through a personal, social political and historical context. TWO Levels of CBT Therapist may concentrate on identifying and reexamining particular thoughts, thereby changing feelings and behaviours. Or, they may focus in underlying meanings and beliefs and adopt more sophisticated and complex methods of interventions Hypothesis testing Working in an open minded way with a formulation provides a means fro contributing tot eh scientific endeavor involved in finding out which are the best. Most effective and most efficient methods of treatment. Example: the four ways in which psychological life are conventionally catagorised reflect the internal workings and psychological state of a person at a particular point in time For instance changing ones perspective can provide a new outlook that helps dissipate stress, reduce tension, and encourage constructive activity Meanwhile person is interacting with the external world through a personal, social political and historical context. TWO Levels of CBT Therapist may concentrate on identifying and reexamining particular thoughts, thereby changing feelings and behaviours. Or, they may focus in underlying meanings and beliefs and adopt more sophisticated and complex methods of interventions Hypothesis testing Working in an open minded way with a formulation provides a means fro contributing tot eh scientific endeavor involved in finding out which are the best. Most effective and most efficient methods of treatment.

13. CBT Issues CBT should include a developmental ‘story’ explaining why people are biased to think in certain ways Beliefs are not simply challenged directly as irrational Relevant to Psychosis

14. What ‘causes’ Psychosis- what might be in a full formulation Possible Biological Vulnerabilities Stressful Life Events – trauma , abuse, bullying Drugs Having unusual experiences (e.g. voices) How people make sense of unusual experiences What keeps it going ?

15. Generic Cognitive Model of Psychosis

16. What ‘causes’ Psychosis- what might be in a full formulation The assumption here is that these individuals are vulnerable to developing anxiety or depression, and the triggering of unusual experiences as well contributes towards psychosis

17. What do we mean by a Biological Vulnerability?

18. What do we mean by Unusual Experiences?

19. What do we mean by Unusual Experiences?

20. What do we mean by Unusual Experiences?

21. When working with psychosis and beliefs we often end up getting involved in what is real and what is not.Do we need to directly challenge the ‘reality’ of symptoms at any point during therapy?

22. Do we need to directly challenge the ‘reality’ of symptoms at any point during therapy?- there are varied approaches to CBTp- a fear of being too challenging- a fear of collusion

23. Do we need to challenge the ‘reality’ of symptoms ?1. Is it the best way to achieve the aims of therapy?2. What is the aims of therapy?

24. Do we need to challenge the ‘reality’ of symptoms ?3. If the aim is distress reduction, do all ‘psychotic’ symptoms need to be challenged?4. Can people experience ‘psychotic’ symptoms without being distressed

25. Consider psychotic phenomena separatelyDelusions – ParanoiaVoices

26. DELUSIONS / PARANOIA Can people experience ‘delusional beliefs’ without being distressed? Are there any specific criteria than can be used to reliably distinguish a delusion from a non-delusional belief ?

27. DELUSIONS Are there any specific criteria than can be used to reliably distinguish a delusion from a non-delusional belief ? A delusion is ‘not-true’ Not amenable to change

28. DELUSIONS Examples of ‘common’ beliefs and/or experiences which are not based on scientific proof

29. DELUSIONS Examples of ‘common’ beliefs and/or experiences which are not based on scientific proof Astrology Religion Aliens

30. Delusions Large polls of the general population such as Kingdon & Turkington (1994) and Garety and Hemsley (1985) found the following beliefs ghosts 25% telepathy 25-50% Peters et al. (1999) not the content of beliefs that distinguished between delusional patients and new religious movements or the degree of conviction but levels of distress and preoccupation Questions recovery being based on conviction

31. Delusions They are a form of belief Influenced by normal belief development and maintenance factors Scanning Interpretation bias

32. Underlying beliefs of others are threatening and not to be trusted, recently includes family members

33. Delusions Bizarre content is not the focus, distress is always the focus Easy to be ‘distracted’ by bizarre content, and forget empathic engagement Need to assess why a belief is distressing

34. Conclusion Delusional type beliefs can be found in the general public, who are not distressed by them It is the distress which is the focus in therapy No need to challenge what real, just focus on distress

35. VOICES I Are there any specific criteria than can be used to reliably define an auditory hallucination?

36. VOICES Are there any specific criteria than can be used to reliably define an auditory hallucination, as part of a diagnosis? Is there a distinction between voices hearing in non-patients and in those diagnosed? Romme and Escher

37. VOICES So we know many people hear voices and are not distress by them So getting rid of the voice should not be the target How do we understand why some voices are distressing?

38. Back to a basic CBT model The aim is to work on the distress caused by the beliefs or interpretation of an event Hearing a voice is considered an event The aim is NOT to remove the event/voice Reduce distress by working with beliefs

39. Back to a basic CBT model A = The Voice B = (Belief) Voice must be obeyed C = do what voices say, get distressed

40. Common psychiatric beliefs about voices They are completely powerful They know everything They must be obeyed They are uncontrollable They are the Devil/God/CIA/MI5 …. The distress follows from these beliefs

41. An analysis of a voice Voice content ‘Rape and kill, rape and kill!’

42. VOICES CONTENT Critical Kill yourself Cut your wrists

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44. Cross-Sectional Formulation Triggers (cannabis, paranoid thoughts, arousal ) Hear Voices scared, increased arousal pray, hide in church, no sleep attend to relevant stimuli It is the devil trying to possess make me harm people

45. Distress and voices Distress can arise not just from the content and quality of the voice but from the beliefs about the voice

46. VOICES IIWorking therapeutically

47. NORMALISATION Up to 3% population Many cope, even see as a benefit Mixed relationships Useful information (distraction is hard) Historical, cultural perspective HVN magazines (www.hearingvoices.org)

48. VOICE ENGAGEMENT ISSUES May be active during session, make threats Client may fear the reaction of therapist Often think they are alone Need to keep the affect low - normalise Aim is not to ‘get rid of’ but work on why they are distressing - content, beliefs

49. Possible Ways of Conceptualising the Origin of Voices 1 : Voices are the product of a chemical imbalance in the brain 2 : Voices are like ‘waking dreams’ and can reflect current concerns in unusual ways like dreams do 3 : Voices are a version of your own thoughts

50. Possible Ways of Conceptualising the Origin of Voices 4 : Voices are communications via telepathy 5 : Voices are communications from God / spirits 6 : Voices happen when people are stressed/take drugs/ don’t sleep

51. Voice Conceptualisations No ‘right’ way to conceptualise voices Task is not to ‘push’ one conceptualisation onto a client We do raise possible conceptualisations in the context of a formulation where appropriate The aim is work on the distress associated with voices

52. What have we covered? What do we need to cover? Looked at what might trigger unusual exp Looked at delusions and voices individually Looked at maintenance cycles for specific ‘symptoms’

53. What have we covered? What do we need to cover? A longitudinal formulation Allows us to make sense of seemingly unconnected distressing events

54. Longitudinal Formulation What’s needed? Enough developmental information to make sense of core beliefs and assumptions A critical incident (1st episode) The first unusual experiences How they were made sense of What influenced those interpretations What ‘symptoms’ and other problems are now stuck What keeps it going

55. Generic Cognitive Model of Psychosis

56. Generic Cognitive Model of Psychosis

57. Longitudinal Formulation What’s needed? Evidence that current mood will directly influence unusual experiences Anxiety increases frequency of voices Anxiety and depression may influence the content of voices

58. Generic Cognitive Model of Psychosis

59. Generic Cognitive Model of Psychosis

60. Longitudinal Formulation What’s needed? To understand what influences how the individual makes sense of these initial confusing and distressing experiences In psychosis, this tends to be as ‘external’ and ‘threatening’

61. Generic Cognitive Model of Psychosis

62. Longitudinal Formulation What’s influences how we make sense of things? Core Beliefs Isolation Evidence for ‘jumping to conclusions’

63. Generic Cognitive Model of Psychosis

64. Longitudinal Formulation When do we call it symptoms? After a period of stabilisation When it has been diagnosed at such This doesn’t make it any different, it is just the history of how it has been labelled in their psychiatric history

65. Generic Cognitive Model of Psychosis

66. Generic Cognitive Model of Psychosis

67. Longitudinal Formulation What’s influences whether maintenance occurs? Core Beliefs Isolation Continued Drug Use

68. Generic Cognitive Model of Psychosis

69. Generic Cognitive Model of Psychosis

72. JennyJenny believes that other people are always staring at her and saying nasty things about her.Sometimes they say things to each other and sometimes they say things directly to her. Sometimes she thinks she is being watched via the television. She hears voices that other people can’t hear. The voices tell her she is being watched, and say they will hurt her.

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75. Engagement Issues Need to offer them a different type of relationship Engage with what is distressing to the client Client should feel understood & taken seriously – their view is one possible explanation View client as reasonable and rational – struggling to understand difficult experiences

76. Engagement Issues Ongoing process Be flexible with timing and location

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81. What else do we need to consider? Assessment of the client How to integrate assessment information into a formulation (using the model) How to turn the formulation into an intervention

82. Assessment (handout) All factors relevant to the model You are assessing the full history and the whole person, not just the ‘psychosis’ Underlying self/other beliefs Stress at time of onset Personal meaning of symptoms Maintaining factors

83. Assessment (handout) Start with current or past, all information is relevant As relationship develops, guide the conversation to the areas you have heard less about

84. What else do we need to consider? Assessment of the client How to integrate assessment information into a formulation (using the model) How to turn the formulation into an intervention

85. EXERCISE:CASE VIGNETTE (R)

86. What else do we need to consider? Assessment of the client How to integrate assessment information into a formulation (using the model) How to turn the formulation into an intervention

87. Possible Interventions Developing the formulation Psychological insight allows increased control Using it for relapse prevention Awareness of personal vulnerabilities Awareness of triggers Awareness of early signs

88. Possible Interventions CBT for social anxiety At maintenance level At core belief level (self-esteem) Use of behavioural experiments

89. What is aim of CBT for Psychosis ?This Workshop Where Possible: A formulation based approach to help someone understand why they have these distressing experiences or ‘symptoms’ As ever in CBT, the intervention evolves from the formulation To build upon what you already know about CBT for anxiety and depression

90. What is the aim of the formulation and associated therapy ? Reducing distress Providing a less threatening interpretation for currently distressing experiences Provides an alternative to a medical model and all ‘psychotic’ beliefs being true

91. What is the motivation for change? Reducing distress Motivation to take risks in therapy, to make a change that is desired (their goals) BUT …. ‘giving up’ old beliefs and ‘being wrong’ Giving up positive aspects of voice hearing and/or paranoia

92. Case Example Core Beliefs and Paranoia

93. Formulation – ExampleThe role of core beliefs

95. Formulation – ExampleThe role of core beliefs

96. Clinical Cases Paranoia with a direct theme linked to the past Paranoia with a minimal theme linked to the past A voices case based on a trauma history An intervention without a formulation

97. CASE 1

98. Paranoia Case Current Beliefs Early Life History Yorkshire, race, care home, London/punk Trauma Daughter, prison Recent Exacerbation

100. Paranoia Case - Interventions Formulation Paranoia : understandable, protective Strategy maybe ‘out of date’ Lowers his quality of life

101. Paranoia Case - Interventions Formulation : over 10 sessions Paranoia: protective but at a price The red dot incident The role of safety behaviours : ‘checking it out’ Generating alternatives Scripts : for current and relapse prevention

102. Paranoia Case - Interventions Situation = someone mentions prison Thought = they know what I’ve done (fed by ‘core belief’) Emotion = anxiety / anger Behaviour = leave the situation / be hypervigilant

103. Paranoia Case - Interventions Generation of other alternatives Maybe they mentioned prison for a reason not to do with me Even if they have heard I went to prison, they may also have heard I was innocent

104. Paranoia Case - Interventions FlashCard I can over-emphasise the chances of danger, and I know why. Is this one of those times ? Just pause for a minute, think, are there any other possibilities for what I’m thinking. Remember the red-pen event.

105. Paranoia Case - Interventions Unrealistic to remove all paranoid thoughts Attend to what triggers worst moments Mindfullness

106. CASE 2

107. Case 2 Background Second episode Recent beliefs about being spied by TV etc Felt very threatened by lots of people, increasing

108. Case 2 Attend to the stages covered in developing a formulation This one has no developmental history

109. Case 2Stages Establish the theme of current concerns Note – therapist does not focus on the evidence for the current beliefs

110. Case 2Stages Establish the theme of current concerns Note – therapist does not focus on the evidence for the current beliefs Establish how this theme is part of a pattern with previous episodes

111. Case 2Stages Establish the theme of current concerns Note – therapist does not focus on the evidence for the current beliefs Establish how this theme is part of a pattern with previous episodes Focus on a relevant event that may have triggered this type of concern

112. Case 2Stages Establish the theme of current concerns Note – therapist does not focus on the evidence for the current beliefs Establish how this theme is part of a pattern with previous episodes Focus on a relevant event that may have triggered this type of concern Use formulation to suggest an alternative explanation of threatening events

113. What Works for Whom Within CBT for Psychosis Dr Craig Steel Charlie Waller Institute of Evidence Based Psychological Treatments University of Reading, UK.

114. Cognitive Behaviour Therapy (CBTp) for schizophrenia: effect sizes, clinical models and methodological rigour Til Wykes, Institute of Psychiatry, UK. Craig Steel, University of Reading, UK. Brian Everitt, Institute of Psychiatry, UK. Nicholas Tarrier, University of Manchester, UK. Schizophrenia Bulletin (2008)

115. Cognitive Behaviour Therapy (CBTp) for schizophrenia: effect sizes, clinical models and methodological rigour A comprehensive review of evidence base of CBTp Considers the outcome in relation to a variety of symptoms Considers individual and group therapy Considers the issue of trial quality CTAM (Tarrier & Wykes, 2004)

116. Inclusion All patients received standard psychiatric care (TAU, treatment as usual) In the experimental group CBT was an adjunct to treatment as usual (TAU) There was a control group There was an allocation procedure CBT treatment was targeted at one of the following positive negative Functioning social anxiety

117. Exclusion Non CBT Uncontrolled Outcome not based on symptoms E.g. Medication compliance

118. Clinical Trials 34 Trials Included 1978 and 1993 to 2006 23 from 2000 onwards 27 Individual and 7 Group 20 UK based 25 chronic participants 24 Individual CBTp aimed at positive symptoms

120. Individual vs Group CBTp Individual (N = 27) 0.415 (SE 0.08) Group (N=7) 0.386 (SE 0.20).

122. NICE Guideline At least 16 sessions At least 6 months

123. Trauma and Psychosis

124. Trauma and Psychosis Potential Psychological Relationships Impact of ‘core beliefs’ during development Co-morbid diagnosis of PTSD and psychosis Psychotic symptoms may constitute a traumatic event Traumatic event may be a ‘stress’ trigger for psychosis Flashbacks or intrusions may be appraised in a ‘psychotic’ manner

125. Developmental trauma That is, childhood trauma, bullying, abuse etc. How does this relate to psychosis, it is prior to onset. Impact on the vulnerabilities Cognitive vulnerabilities: ‘core’ beliefs

126. Developmental trauma Negative beliefs about self, world and others often associated with psychosis I am bad Others should not be trusted Not exclusive to psychosis, but become relevant when some unusual experiences occur.

129. Intrusions

131. Intrusions & ‘hotspots’ PTSD intrusions commonly of the worst moments of a trauma (Grey, Young & Holmes, 2002) May be more than one hotspot in a trauma Hotspots associated with a range of emotions - not just fear e.g guilt, shame, anger

132. Grey, Holmes & Brewin (2001)example

133. Relevant Research Morrison : ‘culturally unacceptable interpretations’ of intrusive phenomena Steel: those vulnerable to the development of psychosis are also more vulnerable to more frequent intrusive experiences after a stressful event The role of unusual beliefs as a vulnerability factor and relevant to interpretation

134. CASE 3

135. Jane Paranoia wars local children bombs Voices variable in content threatening , abusive controlling

136. Jane CSA, generally controlled (Early life events) I am a bad/worthless person, I deserve punishment Other people are not to be trusted Onset at 2nd Pregnancy Beliefs about voices From God Powerful Can punish her

138. Jane Current voices assessed (normalisation) Reference to difficult childhood Abuse discussed – briefly Discussion of similarity of content of voice and her reaction to it c.f. childhood Work in integrating an adult relationship within the voice reaction

139. Jane Voices not as powerful Less sure voices from God Able to ‘pity’ the voices

140. Jane Situation = CPN away Thought = on purpose, she hates me (fed by ‘core belief’) Emotion = sadness Behaviour = leave, don’t contact CMHT

141. CASE 4

142. Gary 35 year history of voices, visions, paranoia. Intense periods of distress, but religious experiences also form a major part of his life Potential for a formulation originating from first voice hearing experience at a party Intervention was talking & sleep advice

143. End