Cognitive behavioural therapy for psychosis in 2005 Ben Smith, D.Clin.Psy. Research Clinical Psychologist

1. Cognitive behavioural therapy for psychosis in 2005Ben Smith, D.Clin.Psy.Research Clinical Psychologist Department of Mental Health Sciences University College London Psychological Therapies in the Mainstream Swansea 10th June 2005

3. Psychotic symptoms and cognitive behavioural theory Delusions are erroneous beliefs involving a mis-interpretation of perceptions or experiences; hallucinations are distortions of perception (DSM-IV-TR; 2000) Perceptions, distortions and interpretations are therefore central to the positive symptoms of psychosis Cognitive behavioural theory emphasises the role of mis-perception and mis-interpretation in the development and maintenance of all psychological disorders

4. Cognitive behavioural therapy for psychosis in 2005 Theoretically CBT and psychosis should match Despite this CBT for psychosis is new and still developing In the NHS in 2005 CBT for psychosis remains largely unavailable British research groups continue to make important theoretical and therapeutic advances

5. Cognitive theoretical advances in psychosis In the last 5 years theoretical models have started to provide a framework upon which CBT for psychosis can develop Garety et al (2001) and Morrison (2001) proposed multi-factorial cognitive models of positive psychotic symptoms The theoretical understanding of the negative symptoms of psychosis (from a cognitive perspective) remains poor

7. Morrison (2001) - An integrative cognitive approach to hallucinations and delusions Positive symptoms are conceptualised as intrusions into awareness (e.g. hallucinations) and culturally unacceptable interpretations of these intrusions (e.g. delusions) The interpretation, rather than simply the intrusion, causes distress and disability Symptoms are maintained by mood, arousal and mal-adaptive cognitive-behavioural responses (e.g. avoidance)

8. Theory-practice links in CBT for psychosis Theoretical models guide the development of idiosyncratic case conceptualisation and treatment in CBT for psychosis Theories have allowed clinicians to make sense of often complicated and confusing symptoms CBT for psychosis in 2005 is therefore theory (rather than technique) driven This parallels CBT for other disorders where treatment is clearly theory driven (e.g. PTSD - Ehlers and Clark, 2000)

9. Over-arching aims of CBT for psychosis To reduce the distress and disability caused by symptoms To improve understanding and self-management To reduce the risk of further relapse To improve mood and self-esteem To involve the client as an active participant in treatment

10. Therapeutic style in CBT for psychosis Engagement is a pre-requisite of successful CBT for psychosis (experiences of stigmatisation are common) Interventions are characterised by collaborative empiricism and guided discovery Therapists must be open-minded, validating & normalising Flexibility in location and length of sessions is important

11. Therapeutic style in CBT for psychosis - II Collaboration is essential for good outcome Examples of a collaborative approach…. ‘What shall we try to do about this then?’ ‘What do you think is best?’ ‘What are our options?’ ‘So, what are we saying here?’ ‘What does that tell us then?’

12. Tasks for therapist & client - Formulation Collaboratively construct a model that makes symptoms and distress understandable and explainable Develop an alternative, non-psychotic model of experiences that is acceptable and non-stigmatising Develop a plausible ‘biases-in-psychological-processing’ explanation of experiences Connect up seemingly unconnected factors - beliefs, life events, emotions, thoughts, behaviours and symptoms

13. Tasks for therapist & client - Cognition Identify, understand and analyse key cognitions such as….. ‘These voices are uncontrollable’ ‘My illness is uncontrollable, the medication is pointless’ ‘Schizophrenia means I have a lifetime of illness ahead’ ‘All this mental torture is coming from others - not me’

14. Tasks for therapist & client - Cognition II Challenging negative beliefs about the controllability of illness/symptoms improves outcome in non-psychiatric conditions (e.g. Petrie, 2002) 55% of patients with a chronic psychotic illness are not adherent with their medication (Fenton et al, 1997) Cognitions about the controllability and treatability of psychotic symptoms can impact not only on mood and symptoms but on behaviour (e.g. medication adherence)

15. How can we achieve this cognitive change? The formulation is the focal point for all change Normalise the psychotic experience (you are not alone) Learn that steps can be taken to reduce the likelihood of relapse and chronicity, distress and disability Learn that having a psychotic illness does not necessarily equate to a lifetime of illness

16. How can we achieve this cognitive change? II Develop psychological insight (e.g. ‘At least some of this mental torture is to do with me and how I am coping’) Gather information about how others cope (engender hope) Hearing Voices Network (HVN) - voices are common, understandable and not ‘mad’ Information can change your mind (e.g. ‘Suspiciousness is ubiquitous, normal and sometimes useful’; Freeman et al, 2005) Make predictions, test them out, review the prediction (e.g. ‘I can trust no-one’)

17. Tasks for therapist & client - Behavioural Address and reduce ‘safety behaviours’ - strategies that are used to prevent harm (e.g. avoidance) but in fact serve to maintain beliefs (fearful predictions) and symptoms Engender self-control and empowerment (mood improves) Learn from behavioural change - ‘There is something I can do that helps. It isn’t all uncontrollable’ Focus on family and social contexts

18. Is there an evidence base for CBT psychosis? NICE schizophrenia guidelines (2002) - based on rigorous meta-analysis of ‘high-quality’ RCTs NICE (2002) - ‘Psychological interventions should play a key role in the treatment of schizophrenia. The best evidence is for CBT and Family Intervention (FI)’ NICE guidelines now explicitly recommend CBT be offered as a treatment option

19. Is there evidence for CBT psychosis? - II The most convincing evidence is for symptom and distress reduction especially at follow-up in persistent symptom groups (e.g. Tarrier et al, 1998; Sensky et al, 2000) Individual CBT and longer interventions (>6 months) Only limited evidence of improvements in mood, relapse, social-functioning and self-esteem Evidence in early intervention is encouraging (e.g. Lewis et al, 2002; Morrison et al, 2004)

20. Has our enthusiasm for CBT for psychosis clouded our judgement of the evidence? CBT trials cannot be double-blind placebo trials Effect sizes are small and not all results are significant Turkington & McKenna (2003) BJPsych, 182, 477-479 CBT works for some people some of the time Theory, therapy and evidence are still evolving

21. Ongoing research - The PRP trial PRP - Prevention of Relapse in Psychosis The PRP trial aims to investigate and intervene in relapse from a psychological perspective Birchwood (2000) - up to 80% relapse over 5 years Relapse can be seen as ‘toxic’ - loss of social role, social network and hope, with increases in low-mood and stigma

22. The PRP trial - design and methodology Grantholders: Philippa Garety, Elizabeth Kuipers, Paul Bebbington, David Fowler and Graham Dunn Research Co-ordinator: Daniel Freeman 5 Research Clinical Psychologists; 10 Research Workers A multi-centre RCT with (N=301) participants

23. The PRP trial - design and methodology II Independent randomisation to CBT, FI or TAU Blind assessments Manualised interventions (audiotaped for adherence) All baseline assessments completed July 2004 Interventions end July 2005 Final follow-up assessment July 2006 Results available in 2007

24. The PRP trial - aims and objectives To compare CBT with routine treatment for reducing relapse and symptoms To compare CBT and FI on a range of outcomes To investigate mechanisms of change in CBT and FI To inform and test a cognitive model of the positive symptoms of psychosis (Garety et al, 2001)

25. Dissemination of CBT psychosis in the NHS What are the determinants of a successful dissemination? Continuing to develop a therapy that works Political will Funding Time and resources Training skilled mental health professionals (e.g. SLAM)

26. Future directions for CBT in psychosis Exactly how does CBT work in psychosis and what works for whom? - (psychosis is heterogeneous) Within anxiety disorders there are specific CBT treatments for specific problems - would this work in psychosis? Theory and therapy need to be mutually enhancing Keep an open mind……..