Cbt with positive symptoms
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CBT with positive symptoms. Positive responders to CBT. Those who respond best are : Anxious & distressed by symptoms Have some insight, even if fluctuating Also respond best to medication - symptoms remit without CBT , but :

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Positive responders to CBT

Those who respond best are :

  • Anxious & distressed by symptoms

  • Have some insight, even if fluctuating

  • Also respond best to medication

    -symptoms remit without CBT , but :

    - CBT offers understanding & ‘integration’, reduces relapse, improves social functioning

    (Garety et al, 1997)

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Assessment & engagement

2 elements:

  • Understanding of why person believes what they believe

  • Providing credible alternatives

  • person previously dismissed circumstances leading to psychotic episode as irrelevant

  • Explanations solely based on biological factors lack credibility

  • Explore their understanding

  • Explore effects on sleep, anxiety, depression

  • Develop collaboration

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Building a rapport

  • Dependent on personality

  • Difficult to work as ‘therapist’

  • Offer broader discussion, ie housing etc

  • Clarify THEIR agenda, what is important to them

  • Use alternative team members for specific concerns

  • Persistence : but care not to harass, be coercive, deny choice

    or be probing & cajoling

  • Warmth & humour can be misinterpreted – watch for persons reaction

  • Laughter & silence should be carefully handled initially

  • Establish & use a common language

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Issues that may influence progress or approach

  • Vulnerability :Intermediary personality factors

    ie, perfectionism, paranoid character

  • Abnormalities to brain structure or function,indicated by delay in developmental milestones, solitary play

    (Jones et al,1994)

  • Infection

  • Drugs

  • Life events

    Could be a combination

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Consider frequency & thought processes

  • Don’t try to do too much in one session

  • Consider length of time for rumination & building delusional formulation. More frequent appointments may be needed to provide explanations/ offer alternative

  • Leave enough time between sessions to allow for reflection & discourage sense of ‘harassment’

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Duration of sessions

  • Should be sensitive to SU rather than professionals practice/routine

  • Allow time for explanations

  • Consider length of attention span

  • May be better shorter but more frequent sessions

  • Need to allow for thought processes

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  • Aim for sessions to be positive, enjoyable/ helpful

  • Ensure understanding

  • Let SU take the lead

  • Explore their models first

  • Don’t refute their explanations

  • Offer alternative explanations : Give timely information, leaving more information for further visits promotes future engagement

  • Use vulnerability/ stress model for explanation

  • Normalise but don’t minimise

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Approach (cont.)

  • Keep open mind

  • Don’t pressure –will tell you when they are ready, may fear focussing may bring on symptoms

  • Review stress management & coping skills

  • Readjust expectations- aim for convalescence, ‘feeling better’, small steps

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Explaining psychosis using ‘normalising’ rationale

  • Can help ‘integrate’ experience

  • May vary in how much the person wants an explanation (‘integrators’ seek understanding)

  • Need to consider engagement

  • Need to be guided by the individual

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Vulnerability model

Draws together components : predisposition, precipitation, perpetuation

  • Explains that problems can be brought about by stressful circumstances if they are vulnerable

  • Multi-dimensional cause – management multi-dimensional

  • Contrasts to theories that over-simplify a complex disorder, ie biological

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Delusions / beliefs

  • Collaborative assessment of supporting & disconfirming evidence is essential

  • ‘stalemates’ frequent where alternatives are not forthcoming or accepted – behavioural approaches: diversion & reducing time for rumination, focus on engagement. ‘agree to disagree’

  • Explore alternatives for specific symptoms

    Anxiety = giddiness = ‘controlling mind’

  • Explain autonomic thoughts

    Because you think something doesn’t mean:

    ‘it is true’ ‘you are evil’ ‘you have to act on it’

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Do you think I’m ill?’

Therapist :‘beliefs may not be as they seem/ you describe them, but could be stress or illness related’

  • May be seized upon negatively

    - ‘You are like all the others’

    Solution: Move towards self discovery through their providing evidence, checking out, draw to own conclusions

    Therapist : ‘what do you think?’ ‘how important is what people think to you?’

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Approaches to delusional beliefs

‘I’m not yet convinced you are ……….. If others did believe you what would that mean?’

  • Explore additional material/ feelings as may assist identifying key problems

  • Straight forward discussion of evidence can lead to increased delusional material to support belief

  • Where delusions are grandiose, issues of self esteem are common

  • Consider loss of delusion/ belief, ie, what it mean not to be ………… in reality

    - explore further, becomes a focus for therapy, possible relationship difficulties

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  • Those who are isolated

  • Those who have cut off from social interaction

  • Those who have developed a resistance to change

  • Those who have severe concurrent affective symptoms


  • May need to wait response from medication before commencing CBT

  • Can listen, allow for expression

  • Behavioural approaches

  • Work with family

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  • Assess reasons for & work with isolation

  • social phobia

  • Delusions of reference

  • Fear of exacerbation of symptoms

  • Discuss avoidance

  • Explore impact of isolation

    - possible ostracising by others where discussion is uncontained

    - social withdrawal or relationship difficulties

  • Consider containment in social environments

  • Allow for discussion in planned sessions

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Thought interference

  • Distressing – feel they have no privacy or freedom from interference

  • Commonly explained/ expressed as ‘telepathy’

  • Reference may impact on activity/ isolation

  • Distracting during therapy/ sessions

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  • Use of different mediums, ie art, writing

  • Reality testing

  • Socratic questioning

    -enquiry without making assumptions

    - conversational rather than staccato

  • Guided discovery

  • Psycho-education – timely, sensitive information

  • Clarity on explanations

  • Homework – enhances collaboration, involvement, control

  • Normalising symptoms

    -reduces fear & confusion

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Beliefs about hallucinations:

  • Reattribute as thoughts

  • Eliminate possibility of drugs, deprivation states can cause ‘voices’

  • Discuss similarities to dreaming

  • Explore & work with trauma

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Useful phrases

  • ‘I need to know more before I can agree’

    Where SU responds to smile/ non verbal cue by becoming guarded:

  • ‘Did I do something to upset you?’

  • ‘Did my smiling at what you said concern you?’

  • ‘I’m feeling ……….. , is that how you feel?’

  • ‘At the moment I’m not sure but I would like to listen to know more’

  • ‘I don’t understand, would you try to explain about…/ what you are thinking…’



    ‘ But if this was the case,……….’

    ‘How could this be so?’