1. Early Intervention in Psychosis ‘At Risk Mental States’ Cognitive Therapy for People at High-Risk of Developing Psychosis Dr. Aoiffe KilcommonsClinical Psychologist Dr. Sophie ParkerClinical Psychologist

2. Cognitive therapy main intervention Cognitive therapy main intervention However it can be helpful to interweave alternative interventions However it can be helpful to interweave alternative interventions Use of case management skills such as assistance with housing, bills, negotiations with college/employer/neighbours. Use of case management skills such as assistance with housing, bills, negotiations with college/employer/neighbours. Crisis intervention skills at times such as becoming homeless, traumatic events etc. Encourage strategies to manage these crises. Crisis intervention skills at times such as becoming homeless, traumatic events etc. Encourage strategies to manage these crises. Framework of CT for ARMS

3. Develop therapeutic relationship Develop therapeutic relationship Assessment Assessment Establish shared problem list Establish shared problem list Translate into ‘smart’ goals Translate into ‘smart’ goals Formulation Formulation Interventions derived from formulation Interventions derived from formulation Relapse prevention Relapse prevention Intervention Process

4. Practical Offer flexible appointments, time and venue Offer flexible appointments, time and venue Rapid response to referral Rapid response to referral Consistency Consistency Therapy Socialise to cognitive model, focus on distress Socialise to cognitive model, focus on distress Success early in therapy Success early in therapy Problem orientated Problem orientated Collaborative, shared, prioritised, SMART goals Collaborative, shared, prioritised, SMART goals Language Language Incorporate case management strategies Incorporate case management strategies Engagement

5. Common Themes in EDIE 1 Problem Lists (French and Morrison, 2003) Anxiety - I’m going mad / identity - Social anxiety - Worry & metacognition - PTSD Mood & activity - Boredom / depression / hopelessness / self-esteem - College/job/money Social Networks - Relationships – friends, family, partners - Loneliness / lack of confidant

6. “I am unhappy with where I live.” “I am unhappy with where I live.” “I feel anxious and paranoid when I leave the house.” “I feel anxious and paranoid when I leave the house.” “I worry that people know what I’m thinking”. “I worry that people know what I’m thinking”. “I feel depressed.” “I feel depressed.” “I worry about people laughing at me when I go out.” “I worry about people laughing at me when I go out.” “I need to get a job.” “I need to get a job.” “I want more money.” “I want more money.” “I have difficulties expressing myself”. “I have difficulties expressing myself”. “I want to know what is wrong with me.” “I want to know what is wrong with me.” “I need a girlfriend.” “I need a girlfriend.” Problems

7. When I go out, I would like to be able to distinguish with more certainty if people are laughing at me or whether I just feel this is the case (reduce distress from 60% to 30%). When I go out, I would like to be able to distinguish with more certainty if people are laughing at me or whether I just feel this is the case (reduce distress from 60% to 30%). To begin to understand if what I am experiencing is the start of psychosis. To begin to understand if what I am experiencing is the start of psychosis. To find out what alternative accommodation is available and contact various housing agencies in order to get on their waiting lists. To find out what alternative accommodation is available and contact various housing agencies in order to get on their waiting lists. If I felt less anxious I would like to be able to leave the house and go to the local shops when I felt like it (and at least 3 x a week). If I felt less anxious I would like to be able to leave the house and go to the local shops when I felt like it (and at least 3 x a week). Goals

8. Formulation Normalisation Working with metacognitive beliefs Generating possibilities for intrusions Safety behaviours Selective attention Activity scheduling Relapse prevention Intervention Strategies

9. The formulation using the intrusions model (Morrison 2001) is developed within sessions 1 & 2. The formulation using the intrusions model (Morrison 2001) is developed within sessions 1 & 2. The aim is to help the person make sense of their experiences in more rational and less distressing ways The aim is to help the person make sense of their experiences in more rational and less distressing ways One aim of this process is also to highlight occasions when their interpretations may not lead to distress. One aim of this process is also to highlight occasions when their interpretations may not lead to distress. Formulation

10. Morrison, A. P. (2001) The interpretation of intrusions in psychosis: An integrative cognitive approach to hallucinations and delusions. Behavioural and Cognitive Psychotherapy, 29, 257-276. CT for ARMS: Morrison’s cognitive model of psychosis

11. What happened Event /intrusion How I make sense of it Beliefs about yourself and others Life experiences What do you do when this happens How does it make you feel CT for ARMS: Client friendly version of Morrison’s cognitive model of psychosis

12. The way that I make sense of this Other people talk about me in a negative way People mumbling are really swearing at me What happens Worry about what people think about me See people in street mumbling How it makes me feel Depressed Paranoid Angry What I do Listen out for people talking about me Keep head down Put glass against the wall Punish self for bad thoughts Beliefs about myself and others I am not a good person You must be on your guard Other people are out to get you Paranoia keeps me safe Life Experiences Very religious family Bullied at school Parents very over protective

13. What I make of it I must be going mad I must not let other people see I am going mad When mum is drunk she tells me I am going mad What happens Hear whispering and laughing See bodies Think about harming people How it makes me feel Angry Agitated Anxious Depressed Fear What I do Try to stay in total control of thoughts and behaviours Look out for things happening to me How do you understand yourself and others? I should be in total control I am going mad The symptoms I am experiencing mean I am going mad Life Experiences Have always been interested I what happens in a psychiatric ward

14. What happened Going out in public Day dreaming on the bus What I make of it Other people people know what I’m thinking Beliefs about myself and others I’m odd, weird Worrying helps me cope I must be in control of my thoughts at all times People will look down on me for showing anxiety Experience Lonely childhood. Bullied. Parents separated age 10 years What I do Watch out for people looking at me and giving me strange looks Worry about it How it makes me feel uneasy insecure paranoid

15. What I make of it They’re watching me They’re out to get me What happens I saw someone looking at me How it makes me feel Racing heart, churning stomach, sweating, Anxious, upset What I do Keep my head down and don’t look at anyone Leave the situation How do you understand yourself and others? I’m different from everyone else I’m weird My father had mental illness so I might too Life Experiences Bullied at school Father had mental illness problems

16. This uses the existing body of work from Kingdon and Turkington (1994). This uses the existing body of work from Kingdon and Turkington (1994). Their strategy allows distress associated with symptoms to be managed by normalising the experience. Their strategy allows distress associated with symptoms to be managed by normalising the experience. In our strategy we use the same approach but more in line with the intrusions model we utilise a paper by Rachman and Silva discussing intrusive thoughts. Thus moving towards a truly normalising approach. In our strategy we use the same approach but more in line with the intrusions model we utilise a paper by Rachman and Silva discussing intrusive thoughts. Thus moving towards a truly normalising approach. Normalisation

17. The model of psychosis described directs treatment towards working with metacognition. The model of psychosis described directs treatment towards working with metacognition. Negative beliefs regarding the appraisal of the voices as being dangerous or uncontrollable may give rise to transition to psychosis. Negative beliefs regarding the appraisal of the voices as being dangerous or uncontrollable may give rise to transition to psychosis. Metacognition

18. As with clients who have established psychotic symptoms generating possibilities for the psychotic experience can be extremely helpful in terms of assessment and also treatment. As with clients who have established psychotic symptoms generating possibilities for the psychotic experience can be extremely helpful in terms of assessment and also treatment. The development of an exhaustive list is essential, with belief ratings, and emotions generated associated with this belief. The development of an exhaustive list is essential, with belief ratings, and emotions generated associated with this belief. Subsequently, work through each possibility generating evidence for and against each. Subsequently, work through each possibility generating evidence for and against each. Generating Alternative Explanations

19. GENERATING ALTERNATIVE EXPLANATIONS Advantages / disadvantages Exhaustive range of possible explanations  Socratic dialogue  Being creative Belief ratings for each (0-100%) with associated emotions Evidence for and against each one

20. ALTERNATIVE EXPLANATIONS: Case Example Situation: I have been seeing things like dead bodies or images of myself hung in my wardrobe Current explanation: I am going mad/ have a brain tumour Current mood associated with this belief: Frightened Other explanationsBelief ratingAssociated Mood God is punishing me for something I have done in a previous life 40 %Frightened Ghosts75 %Scared Brain tumour100 %Doesn’t bother me Going mad85 %Depends, okay or very frightened Perhaps stress and Kate’s life90 %Unsure

21. EVIDENCE FOR AND AGAINST: Case example Belief to be examined I have a brain tumour Associated Mood Doesn’t bother me Belief rating 100% Evidence forEvidence Against I am having lots of strange experiences. People with a brain tumour have strange experiences I have bad headaches at times People with brain tumours get progressively worse I have been getting better I have been learning to make sense of these experiences When I make sense of them they reduce and go away, this would not be the case if it was a brain tumour My headaches usually respond to paracetamol, which would have little effect on a tumour Belief rating (re-rating) Alternative Thought 70% Maybe things are more related to stress which I suppose would also explain the headaches Associated Mood More relaxed

22. Alternative Explanations: Case example What happened Walking through the supermarket One way of Thinking “Others can read my mind” Things I do Look out for strange looks Worry Feelings Insecure Paranoid Another way of thinking “Oh I’m being silly – it’s not happening” Feelings Reassured Things I do Carry on as normal OR

23. Safety behaviours in the maintenance of anxiety disorders have been extensively reviewed. Safety behaviours in the maintenance of anxiety disorders have been extensively reviewed. The model of psychosis presented here emphasises the idea of self and social knowledge. Safety behaviours perpetuate faulty self and social knowledge. The model of psychosis presented here emphasises the idea of self and social knowledge. Safety behaviours perpetuate faulty self and social knowledge. A full exploration of safety behaviours should be undertaken and these should be highlighted and experiments undertaken to test their utility for the client. A full exploration of safety behaviours should be undertaken and these should be highlighted and experiments undertaken to test their utility for the client. Safety Behaviours

24. Examples of Safety Behaviours ExperienceInterpretationSafety Behaviour Saw people laughing whilst out walking People in the street are talking about me To keep head down, walk fast and purposefully Visual hallucinatory experience, seeing a man sat on a chair I am going madNot look at the chair and get out of the room as quickly as possible Shop keeper looking at me They know I am going mad Said very little (if I talk it will confirm I am going mad). Visual hallucination of dead body on wardrobe I am going mad/ losing control Hide head under the cover

25. BEHAVIOURAL EXPERIMENT: Case example Thought to be tested: When I feel anxious other people will notice my hands shaking and will think I’m weird and laugh at me. Belief in thought: (0-100%) Before experiment: 100% After experiment: 40% Experiment to test thought Likely problems Strategies to deal with problems Expected outcome Actual outcome Alternative thought Do usual (5 minutes), exaggerate (5 minutes), drop (5 minutes) I will feel too scared to do what’s asked of me Tell my self that this is worth a go, it’s only for 15 minutes People will think I’m weird I looked more anxious when I did my usual things Maybe some things I do don’t help me

26. This has been strongly implicated in our experience of working with this client group. This has been strongly implicated in our experience of working with this client group. Many clients have discussed this as a means of confirming their experiences in conjunction with safety behaviours as indicating they are at risk of impending psychosis. Many clients have discussed this as a means of confirming their experiences in conjunction with safety behaviours as indicating they are at risk of impending psychosis. Selective Attention

27. Frequently people are beginning to isolate themselves, reducing the frequency and duration of contacts they have with people and this leads into further preoccupation with thoughts. Frequently people are beginning to isolate themselves, reducing the frequency and duration of contacts they have with people and this leads into further preoccupation with thoughts. The use of activity scheduling can be a valuable means of monitoring and impacting upon activity levels. The use of activity scheduling can be a valuable means of monitoring and impacting upon activity levels. Activity Scheduling

28. Familiar cognitive interventions developing blueprint of therapy. This should be provided in a medium which is amenable to the person eg written or audio tape. Staying Well

29. To increase awareness in primary care services, secondary care services, voluntary sector, further education and the community To increase awareness in primary care services, secondary care services, voluntary sector, further education and the community To increase referrals through: To increase referrals through: 1. Training for potential referrers 2. Rapid response 3. Flexible approach to client 4. Positive, user friendly service Our Approach