CBT for psychosis PREP Kate Hardy, Clin.Psych.D Post Doctoral Fellow Prevention and Recovery of Early Psychosis CBT for psychosis Kate Hardy, Clin.Psych.D Post Doctoral Fellow Prodromal Assessment, Research and Treatment Team (PART), UCSF Kate.Hardy@ucsf.edu

Objectives Be able to differentiate between the terms ultra high risk and first episode psychosis Have an understanding of CBT in relation to psychosis and the evidence base behind this Be able to recognize the key aspects of CBT for psychosis including the reduction of distress rather than the removal of symptoms Have reviewed any concerns regarding practicing CBT for psychosis Focus is on UHR and FEP – explain why this is the case Review some of the evidence base for cbt and psychosis (talk about how not here to sell it, people are obviously here so are interested in it but need to review evidence base for doing it) Later will be looking at some of criticisms. Look at key concepts of cbt for psychosis Review concerns regarding cbt for psychosis (unless done this in review already)

Disorganized symptoms Associated mood symptoms What is psychosis? Positive symptoms Negative symptoms Disorganized symptoms Associated mood symptoms Get them to answer first then quickly run through Positive symptoms (something in excess) – typically hallucinations and delusions including paranoia and suspiciousness, disorganized communication, thought disorder Negative symptoms (something missing) – wanting to spend time alone, difficulty experiencing and expressing emotion, decreased motivation Disorganization – trouble with thinking, concentration, attention, impaired hygiene, odd behavior Mood symptoms – depression, anxiety (and all things that go along with that – sleep, appetite, suicidal ideation, irritability Refer to Bentall paper – not necessarily about labeling an individual as schizophrenic. Why give paper – to show different perspective and way of thinking about schizophrenia and psychosis. Also to show how historically has been labeled differently through the ages and now how new research into cognitive aspects of psychosis allow us to think differently about the difficulties the individual is experiencing which led to development of specific psychological interventions which previously would not have been thought possible (ununderstandable) Will talk about CBT for psychosis

Psychosis: the early course Early Detection & Intervention in the at-risk phase Early Intervention after onset of psychosis (EIS) Psychosis “DUI” premorbid phase Focus is on early psychosis and uhr as this is what PREP is. Interventions and approaches that we will talk about can be applied to more chronic presentations Talk about how uhr identified later Dui – illness, dup from psychosis to treatment Prodromal – early symptoms (but not prodromal until retrospective) very early symptoms psychotic symptoms Treatment & Recovery Relapse? The typical course of psychosis

Phase specific psychological treatments AT RISK PHASE – identify symptoms and prevent transition to psychosis ACUTE – maintain safety, decrease positive symptoms, decrease associated distress RECOVERY - promote medication adherence, identify early warning signs and develop relapse signature

Ethics of intervening in the at risk period Use of anti psychotic medication with young people who don’t have a diagnosis of psychosis Stigma associated with treating individual for something they don’t yet have Still no answer to this – debate rages on Bentall and Morrison (2002) – argue medication is unethical and potentially harmful. Little known about effect of psychotropic medication on the developing brain. Also effect of side effects on social development – olanzapine and sex dysfunction and weight gain. Assessments not sensitive. False positives – results in people receiving medication who don’t need it. Contact with services stigmatising and risk of labelling – McGorry 2001 Bentall & Morrison 2002 argue for the use of psychological interventions alone. In particular CT. Working with help seeking individuals. Focus on problem list collaboratively drawn up with client. Avoid stigmatising services (access via primary care etc) and avoid labelling.

What is CBT for psychosis? CBT focuses on reduction of emotional distress (depression, anxiety, trauma etc) through altering cognition and behavior In psychosis – focus is on a cognitive model of the formulation and maintenance of positive symptoms Also ‘affective disturbance’ influences and maintains this process Cognitive model – appraisal of anomalous experiences + reasoning and perceptual biases (will look at models later) Gillian Haddock and Shon Lewis paper looks at the data on CBT intervention in various stages. Not going to go through this in session but will say – Different approaches from CT alone (Morrison) to CT and ap’s (McGorry) to ap’s alone (McGlashan)

What is CBT for psychosis - II Focus is still on collaborative approach Client’s perspective is taken seriously Shared formulation developed to attempt to understanding the meaning of psychosis to the individual May offer more flexibility in duration of sessions, frequency, goals etc to accommodate difficulties with attention and concentration Gillian Haddock and Shon Lewis paper looks at the data on CBT intervention in various stages. Not going to go through this in session but will say – Different approaches from CT alone (Morrison) to CT and ap’s (McGorry) to ap’s alone (McGlashan) Again difference from research to clinical setting. Research has to have strict structure to be adhered to. Clinical work can be flexible and responsive to needs of client (hopefully) Distress can get lost in all this if purely focusing on positive symptoms

CBT, psychosis and distress Birchwood et al. (2004) - not all distress in psychosis arises from positive symptoms Focusing purely on delusions/hallucinations will not address other sources of distress Other sources of distress include post psychotic depression, PTSD, childhood trauma Argue that CT should focus on reducing distress and not on reducing symptoms No other CBT model focuses on symptoms to the detriment of distress. Don’t just focus on ema or low appetite in depression Birchwood study showed could reduce distress associated with hallucinations and distress experienced while frequency and intensity of hallucinations did not change Makes it more collaborative – what the client is distressed by

Deconstructing Schizophrenia Psychotic symptoms on a continua Questions validity of term ‘schizophrenia’ and proposes that we focus on individual symptoms Cognitive processes and biases maintains misperceptions Processes and biases amenable to CBT intervention Acknowledge age of paper – segue into how research in cognitive processes of symptoms of psychosis helped to inform early trials of ct for psychosis Not about schizophrenia as distinct category – talks about how unhelpful that has been through the ages (specifically focusing on reliability and validity) People don’t complain of ‘schizophrenia’ but of specific symptoms Focus has been on biology at expense of mental processes or intentionality as calls it in paper. Not anti biological but suggests that biological research should focus on symptoms Cognition – intentionality how people represent world and have seen that how perceive and represent world is based on schema and core beliefs

Clients’ understandings of psychotic experiences Jim Geekie (2004) Research conducted with 13 participants in NZ Came from observation that clients he was working with focused on ‘explanatory models’ Variety of ways in which people understand their experiences Welcome opportunity to talk in depth about what experience means to them individually Explanatory models – how made sense of what was going on for them The framework developed to conceptualise this incorporated three broad categories; a) ‘the nature of the psychotic experience’, b) ‘the personal meaning of the experience’ and c) ‘narrating experience’. This study emphasised the importance of consulting with the service user regarding their health beliefs and explanatory frameworks.

Cautions against telling the client what their experience is or what it means – may lead to further invalidation Important to recognize that clients want to be active participants in the process of ‘sense making’ Not undermining the medical profession but encouraging acknowledgement of multiple perspectives How does this link to CBT? Helpful to do this within a formulation with the client. But what if clients explanatory framework is totally at odds with professional? Agree to disagree? Hold different beliefs? Agree to explore each others belief system and decide at end of exploration which to hold. Ultimately remember that it is about reduction of distress – not getting someone to see something in same way as you