1. International Review of Psychosis & Bipolarity Compassion-Focused Therapy for Psychosis: empirical review and presentation of a new clinical trial April, 2015 Maria João Martins, Paula Castilho, Célia Barreto Carvalho, Ana Telma Pereira, & António Macedo

2. INTRODUCTION EMPIRICAL REVIEW COMPASSION-FOCUSED THERAPY NEW CLINICAL TRIAL Intervention for Psychosis Pharmacological Treatment International Guidelines (e.g. NICE) recommend CBT for all people with a psychosis diagnosis CBT for Psychosis (CBTp): Psychossocial intervention with more empirical evidence Efficacy studies: Moderate efficacy for positive and negative symptoms, functioning, humor and social anxiety (Wykes et al., 2008) Severe Mental Illness Chronic Course Low compliance (behavioral) Negative Symptoms Cognitive Deficits Secondary effects of medication Psychosis

3. INTRODUCTION EMPIRICAL REVIEW COMPASSION-FOCUSED THERAPY NEW CLINICAL TRIAL Limitations of CBTp High dropout rates and compliance issues Patients’ avoidance of emotionally difficult experiences Absense of consensus regarding benefits in:  Relapse prevention  Quality of life improvement Difficultie in keeping the focus on positive symptoms after symptom remission/reduction Unstable improvement regarding insight Contextual Therapies – Third Generation CBT Focus on context and function of private events (e.g. Thoughts, emotions) instead of focusing on content (absense of content /rationality questioning) Transdiagnostic approach Experiential strategies (instead of language-based) – focus on the body and “here and now” Enphasis placed on quality of life and functioning (instead of symptom relief) Focus on workability of behavior (utility instead of veracity) Mindfulness-based Cognitive Therapy (MBCT, Teasdale et al., 1995) Acceptance and Commitment Therapy (ACT, Hayes et al., 1999) Compassion Focused Therapy (CFT, Gilbert & Procter, 2006)

4. INTRODUCTION EMPIRICAL REVIEW COMPASSION-FOCUSED THERAPY NEW CLINICAL TRIAL Rationale Drive System Soothing System Threat System Excitement; Motivation; Vitality; Search for Pleasure/RewardContemtment; Safety; Afiliation; Connection to others Anger; Anxiety; Disgust; Sadness 3 Affect regulation systems Opiaces; Oxytocin HPA; Cortisol Dopamine

5. INTRODUCTION EMPIRICAL REVIEW COMPASSION-FOCUSED THERAPY NEW CLINICAL TRIAL Rationale Inbalance “Better Safe than Sorry” Threat-focused Mind Attention Thought Behavior Emotions Aim: Balamce between the three systems. Being able to activate an alternative system that deactivates/regulates the threat system – The Soothing System. Organizing the mind with a different motivation (instead of a threat-focused and defense.focused motivation) Compassion (motivation directly related with the soothing system)

6. INTRODUCTION EMPIRICAL REVIEW COMPASSION-FOCUSED THERAPY NEW CLINICAL TRIAL Rationale Compassion: “Basic kindness, with deep awareness of the suffering of oneself and of other living things, coupled with the wish and effort to relieve it” (Gilbert, 2009, p. XIII) SelfOthers Self Compassion Flow How? Using evidence-based strategies (skills training) in order to develop the compassion competencies that activate the Sootyhing System. Examples: Mindfulness training, Breathing Rithms (Soothing breathing rithm), Imagery exercises (compassionate image, compassionate self), behavioral experiments (act as the compassionate self), chair work (talking to multiple selves)

7. INTRODUCTION EMPIRICAL REVIEW COMPASSION-FOCUSED THERAPY NEW CLINICAL TRIAL CFT FOR PSYCHOSIS: WHY? Psychosis is characterized with processing highly focused on threat Patients with several sources of threat (internal and external) with fewer sources of tranquilization (3 systems inbalance) Patients with high levels of shame, self and others-criticism and stigma CFT FOR PSYCHOSIS  Naturally stimulates the Soothing System – a natural regulator of the Threat System (overdeveloped in psychosis patients)  Helps people to disengage from a social ranking mentality (focused on other’s pottentialy harmful power) and to activate afiliative, cooperative and self/others care processes.  The aim is to develop a “compassionate self” that will wprk as a secure base from which to explore and be envolved with fears, trauma, voices and other experiences usually avoided.

8. INTRODUCTION EMPIRICAL REVIEW COMPASSION-FOCUSED THERAPY NEW CLINICAL TRIAL CFT group with improvement regarding social comparison, self-esteem, depressive symptoms, external shame and psychopathology Results CFT group with improvement regarding negative symptoms; CFT group with higher levels of positive emotions and psychological recovery Results CFT group with higher clinical improvement levels when compared to TAU CFT group with higher compassion levels In CFT group: improvement in compassion associated with reductions in depressive symptoms and social marginalization. Results

9. COMPASSION-FOCUSED THERAPY: GROUP INTERVENTION PROTOCOL FOR SCHIZOPHRENIA To develop and test the feasability, efficacy and effectiveness of a group format, compassion- focused therapy based intervention protocol for patients with the diagnosis of Schzophrenia. Main Objetive Description Setting2 Portuguese Hospitals (Aveiro and Coimbra) TypeGroup-format (maximum 10 participants per group) PeriodicityWeekly (1hour to 1h30 sessions) Duration8-12 sessions Inclusion Criteria Diagnosis of Schizophrenia Critical period– until 5 after the first episode of psychosis Clinical stabilization (1 month with stable symptomatology and/or medication) Exclusion Criteria Substance Dependence| Substance-induced Psychosis Significant cognitive impairement Active psychotic symptomatology (when impeditive of participation) INTRODUCTION NEW CLINICAL TRIAL EMPIRICAL REVIEW COMPASSION-FOCUSED THERAPY

10. INTRODUCTION EMPIRICAL REVIEW COMPASSION-FOCUSED THERAPY NEW CLINICAL TRIAL Outpatien units; Inpatient units; Specific Teams Randomization Referenciation Process -Psychiatrists; Clinical Psychologists -Specific Teams (First Episode Teams; Mental Health Community Teams) Explaining the aims of the Study Informed Consent Assessment Moment 1 (1st Part) Psychopathological Assessment (Clinical Interview) Patient does not want to participate (Exclusion) Clinical Criteria (Exclusion) Assessment Moment 1 (2nd Part) (Processes and outcomes baseline – Self- response) N = 60 Intervention Group (CFT + TAU) N =30 Control Group (TAU) N=30 Contact with Family/Caregivers Family Assessment Moment 1 Psychoeducation for Family Family Assessment Moment 3 Family Assessment Moment 2 Group Intervention Protocol 8-12 Weekly sessions Family Assessment Moment 4 Assessment Moment 2(post-intervention – 1 week) + Qualitative feedback Assessment Moment 3 (Follow-up 3 months) Assessment Moment 4(Follow-up 6 months)

11. INTRODUCTION EMPIRICAL REVIEW COMPASSION-FOCUSED THERAPY NEW CLINICAL TRIAL Intervention Group (CFT + TAU) N =30 Loving- Kindness Meditation Mindfulness Skills Self- Compassion Receiving Compassion from others Compassion towards others Psychotic Experience (e.g. voices/delusion s) as a part of the self Breathing Rithms Compassionate Self (acting as) Multiple self dialogue Psycho- education (de-shaming) Emotion- regulation Group

12. International Review of Psychosis & Bipolarity Compassion-Focused Therapy for Psychosis: empirical review and presentation of a new clinical trial Thanks for your attention! April, 2015 martins.mjrv@gmail.com