1. Cognitive Behavioral Therapy for Psychosis: A Workshop for Clinicians
Kim T. Mueser
Center for Psychiatric Rehabilitation
Boston University
(With contributions by Cori Cather, Jen Gottlieb, Eric Granholm, and Kate Hardy)

2. REVIEW: PRIMARY ASSUMPTIONS UNDERLYING CBT
What you think in a situation influences how you feel in that situation
How you feel influences your behavior, or how you act in that situation or related situations in the future
Sometimes how you feel in a situation influences what you think about it
Learning how to evaluate and correct inaccurate thoughts/beliefs related to negative feelings can reduce those feelings and lead to more effective behavior

3. EXAMPLE
You are sleeping in your ground floor apartment and you hear scratching on the window. You think someone might be trying to break into your apartment.
How would you feel in this situation?
What might you do?
What if you remembered that you let your cat out before you went to bed, and she didn’t come back in, so you think maybe it’s your cat at the window?
How would you feel? What might you do?

4. THE COGNITIVE-BEHAVIORAL MODEL
Thoughts
Behavior
Mood
Nobody likes me
I am a failure
People want to hurt me
Isolation
Avoidance
Procrastination
Depression
Anxiety
Fear

5. CBTp PHILOSOPHY
Not so different from CBT for depression and anxiety, really
Human experience and behavior exists on a continuum
Psychotic symptoms (and other schizophrenia symptoms) are amenable to cognitive and behavioral interventions
Reduction of symptoms/distress tied directly to personal goals

6. THE COGNITIVE-BEHAVIORAL MODEL OF PARANOIA
Social Isolation
Avoidance
Hypervigilence
Safety Behaviors
I’m in danger
People cannot be trusted
I’m an outsider
People want to hurt me
Thoughts
Behavior
Emotions
Paranoia

7. MAIN TENETS OF CBTp Symptoms are maintained by appraisal and behavior
Distortions are amenable to cognitive and behavioral approaches
Psychotic symptoms (e.g., delusions) represent an attempt to make sense of negative affect

8. WHICH ACT CLIENTS ARE MOST LIKELY TO BENEFIT FROM CBTp?
Persons with persistent psychotic symptoms
High levels of distress related to symptoms
Preferable if person has some degree of doubt or is able to consider alternative explanations, but not absolutely required
Can be engaged in talk for 30+ min.
Good working relationship with ACT team member(s)

9. OVERARCHING GOALS OF CBTp
Foster a curious attitude about symptoms
Decrease distress about symptoms (but not necessarily frequency or intensity of symptoms themselves!)
Adopt a “living with illness” strategy
Improve sense of personal control
Enhance healthy, effective coping with symptoms
Improve day-to-day functioning
Prevent severe relapse

10. STRUCTURE OF CBTp SESSIONS
Collaborative agenda setting
Review of previous session
Review of homework
Practice new skill in session
Assign homework related to new skill area
Session review and feedback

11. SELECTIVE CBTp SKILLS Engagement and befriending Goal setting
Normalization
Coping strategy enhancement
Cognitive restructuring
Cognitive distortions
Socratic questioning
Behavioral experiments

12. ENGAGEMENT AND BEFRIENDING
Essential to developing therapeutic relationship
Ongoing process throughout therapy
May require increased amounts of befriending depending on symptoms
Paranoia
Hallucinations
Severe negative symptoms

13. BEFRIENDING (Cont’d) Befriending
-Focus on neutral non threatening topics
-No active formulation or treatment
-Non-confrontational
-Empathic
-Supportive
-Accepting
-Non-colluding
Assertive engagement
ASK WHAT PEOPLE DID OVER MEMORIAL DAY WEEKEND FIRST
Phc p45 of kingdon and turkington
Befriending – valuable in developing engagement
Recommend it is being a friend to the person to extent professional relationship allows (think at level of talking with new neighbor not know) also used as intervention in research trials and has been seen to be effective as adjunct to CT. Useful to slip back to when client appears to be disengaging (but need to have lay foundations of befriending first)
Also ideal time to start to form understanding of the client. Not just going into intervention but gaining understanding of topics that are of interest to the client and may be involved in the symptoms also. Can agree to do homework with the client – not know much about buddhism therefore agree to read about this before next session etc
Forming a base from which to begin to have understanding of the client
RICHARD – current client, probably 60% of session is befriending at the moment including going for a walk, but reports from family is he is using what we talk about in other 40% at home
Phoning ahead of time, texting where available, using settings that are client is amenable to etc
Example of when assertive engagement can go wrong – gave wrong message by being too assertive
Also using all resources to engage (Richard example)

14. COMMON ENGAGEMENT DIFFICULTIES IN CBTp
Poor session attendance
Lack of enthusiasm for treatment
Paranoia or low disclosure at outset
Difficulty formulating problems or goals

15. SOLUTIONS: ASSESS UNDERLYING CAUSES
Organizational difficulties: problem-solve solutions
Are you working on what is important to the client???
Is low enthusiasm simply negative symptoms?
Take it slow, build trust, get to know the person, seek to align with their goals or interests
No-showing happens for many reasons: anxiety, disorganization, session is too long, overwhelming
Solution may be as simple as a reminder call, or shortening the session to 30 min
Make sure therapist is not pushing on area that pt is disinterested in or seems too overwhelming, check in A LOT about this. New pt: recent hosp, previously active in college, etc. Family pushing for getting back on track with work, classes, etc. Pt finally acknowledged that he just wants to be able to have fun again.
Don’t take it personally: client may feel enthusiasm for cbt, but may not be able to express it
Paranoid pts: make deals: “what can we do for you to be able to consider that I am not part of the conspiracy?” sharing treatment notes with pt, sign contracts, reason it out. Make a clear strong statement about caring for the pt.
Elicit beliefs about treatment: “this isn’t going to help.”
Has therapist provided enough of a rationale that attendance is important?

16. ASSESSMENT DOMAINS Positive Symptoms Delusions Hallucinations
Disorganized thoughts
Negative Symptoms
Reduced emotional expressiveness
Poverty of speech
Loss of motivation
Decreased activity
Social withdrawal
Quality of Life
Work/School/Recreation
Interpersonal relationships
Physical health/self-care
Cognitive Deficits
Attention
Memory
Executive functions
Insight
Comorbid Conditions
Mood
Substance abuse
Anxiety
Medical Illness

17. AND… Suicidality/homicidality Short and longer term life goals Values
Understanding of psychosis and associated symptoms
Medication adherence

18. DEVELOPING A PROBLEM/GOAL LIST
Collaboration is key
Elicit problem areas by discussing what is distressing to the person and what interferes with the goals or desires
Assess what is most important to guide goal development
Shows the client you are listening and creates a sense that difficulties are contained rather than infinite
Putting their language on the prob list. “aliens are draining my blood”

19. DEVELOP A PROBLEM/GOAL LIST (Cont’d)
Brainstorm and be broad initially, then focus and become more specific
Prioritize and maintain a focus throughout work with person
Include at least one goal related to a psychotic symptom
Other goals may be functional goals related to interference from psychosis or simply life goals

20. SAMPLE PROBLEM LIST
Bryant
“Neighbors are using wireless technology against me.”
“The voices keep me from getting a job.”
“I don’t have anything to do all day.”
“I used to drive and now am worried about doing anything other than walking around the block with my mom.”
“I’m confused about these experiences.”

21. Charlotte
SAMPLE PROBLEM LIST
“Neighbors are watching me and informing the police about me.”
“I am being controlled by their instructions.”
“I feel like my family does not care about me.”
“I need to lose weight.”

22. NORMALIZATION CBT is inherently normalizing
We all experience negative thoughts
We all engage in unhelpful thinking
We all use coping strategies that aren’t always the most healthy choices
Allows for normalizing of psychotic symptoms as well

23. PSYCHOSIS EXISTS ON A CONTINUUM
Stress
Drugs
Trauma
Life experiences
Sleep deprivation
Psychosis
No psychosis

24. NORMALIZATION OF PSYCHOTIC SYMPTOMS
“Normalization is the antidote to stigma”
Avoid catastrophizing
Mental Illness is a common experience (1 in 4 people)
Psychosis can affect anyone regardless of age, ethnicity, gender, SES
Large number of people can overcome symptoms
Symptoms may be viewed positively in different cultures
Normalizing experiences – not dismissing them
Check in how the information is received (invalidating?)

25. NORMALIZING: HOW
Encourage people to research and read personal recovery stories
Elyn Saks
John Nash
Eleanor Longden
Rufus May
Develop library of recovery stories

26. NORMALIZING: HOW
Research prevalence of symptoms (depression, hearing voices, paranoia etc.)
15-20% population experience frequent paranoid thoughts without significant distress
3-5% population have more severe paranoia (Freeman, 2006)
5% of population hear voices (Tien 1991)
People hear voices without seeking mental health services (Romme & Escher 1989)
9% people hold delusional beliefs (van Os, 2000)
Common to see or hear loved one following bereavement (Grimby 1993)
Connect with other people experiencing psychosis
Intervoice
Psycope.co.uk
Paranoia.com

27. VIDEO DEMONSTRATION OF NORMALIZATION

28. RATIONALE FOR COPING STRATEGY ENHANCEMENT
Focus on distressing symptoms
Does not require insight into hallucinations or delusions
Use analogies to other distressing experiences (e.g., migraine headaches, bullying)
Express empathy that this has been difficult and client has done best he/she can
Express optimism that together you can improve coping

29. ASSESS CURRENT AND PAST COPING RESPONSES
Evaluate behavioral, cognitive, affective strategies person has used in the past
Categorize as “helpful” “unhelpful” and “unknown”
Aggressive engagement and extreme avoidance are usually unhelpful strategies
Assign a coping monitoring log
Example (next page) of helpful and not helpful coping strategies for hallucinations
-Often an early intervention to try with people is to talk about “hearing without listening” “seeing without noticing”
-Clinician assesses patient’s perspective of “helpful” and “unhelpful” responses to the hallucinations; What are some ways you have tried to respond to make this better? How much relief have you gotten from this strategy? Has this strategy caused you difficulties in other ways? Are there some strategies you keep trying even though they have not worked? (e.g., calling the police, self-injury, etc) What strategies have you tried that you are pretty sure do not work at this point?

30. HELPFUL NOT HELPFUL Bryant Studying for my exam Watching movies
Telling myself that I can handle this
Going for a walk with mom
Making a list of my good qualities
“I am a good employee and will be an asset to any organization of which I am a part”
NOT HELPFUL
Yelling back to voices
Calling the police
Researching wireless technology
Trying to convince my dad to believe me
Believing what they say
Losing hope about my future
This relates to client hearing voices about being set up not to have a career future d/t voices
Bryant

31. VOICES: COPING LOG Situation What did you hear? How did you respond?
Charlotte
VOICES: COPING LOG
Situation
What did you hear?
How did you respond?
How effective?
Home thinking about watching TV
“She is home.”
Went to bed at 4pm
Not at all
A little
Some
A lot
Change to make specific to a case

32. BEHAVIORAL COPING STRATEGIES
Listen to music or other things
Change your location
Talk with someone, such as trusted other, friend, etc.
Listen to a relaxation tape or do a relaxation exercise
Take a shower
Exercise or go for a walk
Do a hobby or other activity

33. COGNITIVE COPING STRATEGIES
Keep a diary to identify triggers, content of the hallucination and associated thoughts
Focus in on the experience and use distress tolerance skills
Use positive self-talk or prayer
Conduct a pro/con analysis (Pay-off Matrix) with command hallucinations and make your own decision about what to do
Use acceptance-based strategies that don’t actively attempt to suppress hallucinations
Handout payoff matrix

34. ACCEPTANCE AND COMMITMENT THERAPY: THE OTHER ACT
Developed by Stephen Hayes, related to CBTp, but not the same
Agrees with CBT that thoughts are the cause of much misery, but disagrees that solution is to modify the thoughts
Acceptance = understanding of the essential uncontrollability of thoughts
Commitment = commitment to one’s values and goals, and behavior aligned towards them
Suppression of thoughts ineffective
Alternative: “just notice” thoughts, and get on with one’s life
Example: “Thanking” one’s brain for the hallucination
Handout payoff matrix

35. COGNITIVE COPING STRATEGIES (Cont’d)
Hallucination scheduling (permit for period of time during day like worry scheduling)
Review reattribution ideas that have been helpful

36. VIDEO DEMONSTRATION OF UNDERSTANDING VOICES

37. COGNITIVE RESTRUCTURING
Teach clients the connection between thoughts and feelings
Explain that the thoughts people have are often “automatic” and are often related to past experiences (e.g., traumatic) and self-perceptions
Facilitate the examination of evidence supporting thoughts and beliefs underlying strong negative feelings

38. COGNITIVE RESTRUCTURING (Cont’d)
Help clients challenge and modify upsetting thoughts and beliefs that are not supported by evidence by:
Socratic questioning
Exploring alternative beliefs
Behavioral experiments
Teaching how to recognize distorted thinking styles

39. CR TARGETS IN CBTp Accuracy of distressing belief
Utility of holding onto belief
Beliefs about the power and controllability of voices/persecutors
Negative core beliefs about self, other’s perceptions of self, future
Self-stigmatized beliefs related to illness
Beliefs about medications and treatment

40. SOCRATIC QUESTIONING OVERVIEW
-Build rapport, engagement
-Can be an MI technique
-Explore how person understand an event, voice, thought, etc.
-Explore possible consequences of staying
with particular maladaptive thoughts or behaviors
-Help clients to question own inaccurate or distressing assumptions, beliefs and behaviors
-Help clients arrive at a new view of the situation that is more in line with evidence
Note that much of this is the same as socratic questioning for any other kind of disorder – depression, anxiety, etc

41. SOCRATIC QUESTIONING STYLE
Colombo-like style: freely admit confusion when trying to understand something, ask for client’s help in resolving confusion
Ask, don’t tell
Probe questions
Gentle, non-judgmental curious style – don’t interrogate!
Foster client’s curiosity too

42. HOW TO: SOCRATIC QUESTIONING
Explore meaning client attaches to a specific event, voice, thought…
“What does it say about you that you are being watched by the government? If this were not the case, what would that say about you as a person?”
Explore possible consequences of staying with particular maladaptive thoughts or behaviors
“So, what happens if you continue to yell at your voices in public?”
“You spend a lot of time thinking about the idea that you need to develop superpowers to read others minds in order to be happy. I wonder if that gets in the way of you pursuing other meaningful things in life?”

43. HOW TO: SOCRATIC QUESTIONING (Cont’d)
What do you make of the fact that your brother says he can’t hear what you hear?
I wonder if it might be important for us to talk more about your belief that you are adopted, since it is causing so much distress?
I’m curious: what sorts of things got you thinking that your co-workers were poisoning your lunch?
You’ve mentioned that you are being terrorized by people on the street. What’s your sense of why that might be?
Help me understand a bit more about how that brain implant device works.

44. EXPLORING DYSFUNCTIONAL BELIEFS ABOUT VOICES
Common Belief
Examples
Omnipotence
“My voice is all powerful”
“My voice is in charge of everything I do”
Omniscience
“My voice is all-knowing”
“Whatever they say must be true”
Malevolence
“The voices want to harm me, punish
me, or kill me”
Controllability
“If I don’t listen to the voices, they will
punish me”
“I cannot ignore my voices”

45. EXPLORING BELIEFS ABOUT VOICES: HELPFUL PROBE QUESTIONS
Control
How much control do you have over the voices?
Are there some things the voices told you to do where you drew the line and refused?
Power
Who is more powerful, you or the voices?
Do the voices make empty threats?
Move to assessment

46. EXPLORING BELIEFS ABOUT VOICES: HELPFUL PROBE QUESTIONS (Cont’d)
Trustworthiness
Do the voices ever provide contradictory information? Have they ever lied? Can they always be trusted?
Usefulness of Listening/Complying
What important information has the voices given you over the years?
Do the voices ever give you misinformation or lead you on a wild-goose chase?

47. EXPLORING BELIEFS ABOUT VOICES: HELPFUL PROBE QUESTIONS (Cont’d)
Malevolence
Have the voices ever been helpful or kind?
Is there anything you might miss about the voices if they were gone?

48. OVERVIEW: EXPLORING ALTERNATIVE BELIEFS
Teach cognitive flexibility as a skill
Pre-cursor to CR
Begin with coaching around generating alternative beliefs for everyday scenarios
Then progress to scenarios that are tailored to the individual’s delusional or paranoid beliefs

49. EXPLORING ALTERNATIVE BELIEFS (Cont’d)
“Behavioral scaffolding”
Start with identified alternative responses to situation, move toward coaching of additional responses, then to independence with the exercise items
Helpful probe questions:
“What’s another possible explanation for why this may have happened?”
“What factors related to____(the situation/the way the world works/the person involved in the scenario/you) may have caused or contributed to this happening?”

50. BASED ON THE COGNITIVE MODEL
“Someone calls you on the phone and doesn’t leave a message”
It’s the mafia  Anxious, scared
It was a wrong number  Calm
It was a telemarketer  Slightly Annoyed

51. TIPS ON ALTERNATIVE BELIEFS EXERCISE
Coach remains completely neutral about explanations
Goal is not to come to the “correct” appraisal, but rather to acknowledge that most of the time we do not really know why something happens the way it does
Help client “loosen up” their thinking rigidity and reduce “jumping to conclusions”

52. NEUTRAL ITEM: “Clerk at Dunkin Donuts gives you hot coffee when you ordered iced coffee.”
She didn’t hear me correctly.
The ice machine was broken.
She is trying to send me a message that the demons are coming for me.
She is tired because she is sick so she her brain is not working well.
She has her manager watching her today and she is nervous which is making her make mistakes.
I thought I said iced coffee, but I actually said hot coffee.

53. INDIVIDUALIZED ITEM: “The newscaster looks right at the camera and says “Dan.”
He is talking to me because I can forecast the weather.
He is talking about someone famous named Dan.
He is calling the camera man named Dan and it wasn’t supposed to be caught on tape.
Someone in the other room called my name and I misheard it as coming from the TV.
He was saying a different word like Taliban that sounded to me like Dan.

54. GENERATING ALTERNATIVE BELIEFS - JULIE
“While I was in the hospital, I was bothered by a middle-aged man who came to the visitors’ room frequently, and I still worry about that.”
He is my biological father, there to send me that message  Anxious, scared, sad
He was a relative of another patient who visited a lot  Calm
He was a case manager who had a few hospitalized patients on his caseload  Calm

55. EXAMPLE: IN-SESSION CBT TECHNIQUES TO ADDRESS PARANOIA
Client: “I opened the refrigerator at work last week and saw that my lunch bag wasn’t on the shelf I put it on in the morning. I know that they are still trying to poison me.”
Therapist: “Sounds like that was pretty distressing to feel that way at work. How did that affect your work day?”
C: “It was terrible. I couldn't’t concentrate all week and whenever one of the supervisors would try to talk to me, I would have to look away. If I make eye contact with them, then they will be able to intimidate me.”
T: “What did you do with your lunch?”
C: I threw it out of course that day. Didn't’t bring it again for the rest of the week.”
T: “So it sounds like not only did you have trouble concentrating and talking to your supervisors, you also didn't’t eat lunch at all. That must have been a horrible week.”
“How likely do you think it is that your coworkers poisoned your lunch that day?
C: “Pretty likely, I’m almost positive. 80%”
T: “ Why don’t we talk about the details of that incident since it is pretty important.”
“So your lunch was on one shelf and it was moved to the other. That means that there is of course a possibility that coworkers poisoned it. What are some other possible reasons that your lunch could have been moved?”
C: “Maybe someone moved it to fit their lunch in?”

56. IN-SESSION CBT TECHNIQUES TO ADDRESS PARANOIA (Cont’d)
T: “That sounds reasonable. What is another possibility?”
C: “I guess that when someone opened the fridge it fell out cause it was near the front and then they put it back in but forgot which shelf it came from.”
T: “That also makes sense. Anything else?”
C: “Well I guess that since my lunch was in a brown bag someone maybe picked it up and thought it was theirs and then put it back in a hurry on the wrong shelf?”
T: “Again, could definitely be the case. So we have all these other possibilities. How would you feel if any of these possibilities were true?”
C: “Ok. Not scared or worried.”
T: “Do you think you would have trouble concentrating and interacting with your supervisors if one of those reasons were true about your lunch?”
C: “No I think I would do ok.”

57. BEHAVIORAL EXPERIMENTS
Goal is to get additional information about a belief in a “scientific,” mutually agreed upon fashion
Frequently used to examine “safety behaviors” and then to systematically move toward reducing or dropping them
Re-evaluate client’s level of conviction, distress, preoccupation following each experiment
Julie (fear of people spying): “Keep shades up between hours of 1-2pm each day and evaluate mood, thoughts, and consequences”

58. BEHAVIORAL EXPERIMENTS (Cont’d)
In vivo, outside of the office
Sample experiment (“Other people can read my mind”)
Prediction: all people on campus will stare at me and laugh at me if I think a sexual thought
Confirmed if: they look at me and begin laughing within 3 seconds
Procedure:
Find a “high anxiety” (high density) spot on campus
Monitor reactions of people
Debrief with therapist 58

59. VIDEO DEMONSTRATION OF BEHAVIORAL EXPERIMENTS

60. TEACHING HOW TO RECOGNIZE COGNITIVE DISTORTIONS
Easily learned strategy for dealing with negative feelings
As client’s skill at catching and changing cognitive distortions in everyday situations increases, focus gradually shifts to psychotic symptoms
Begin with discussion of how thoughts in a situation affect feelings (and behaviors), and not all thoughts are equally accurate

61. RECOGNITION OF COGNITIVE DISTORTIONS (Cont’d)
Normalize cognitive distortions as common styles of inaccurate thinking that everyone engages in to some extent
Explain how correcting cognitive distortions can reduce negative feelings associated with them
For each type of distortion, briefly explain it, try to elicit a personal example from client
When example elicited, explore why it is a distortion (i.e., why inaccurate)
Then, identify a more accurate thought, and discuss differences in feelings related to the two thoughts

62. COMMON COGNITIVE DISTORTIONS (AKA “COMMON STYLES OF THINKING”)
All or Nothing Thinking
“If I wake up with some symptoms, my week will be ruined.”
“Must,” “should,” or “never” statements
“I should be able to live on my own at this age.”
Overgeneralization
“The receptionist at the clinic didn’t smile at me today: that means everyone hates me there and wants me to go into the hospital.”
Catastrophizing
“The man on the train looked at me sideways when I got on; he is going to try to stab me when I get to my stop.”

63. COMMON COGNITIVE DISTORTIONS (Cont’d)
Mind-reading
“My neighbor said ‘cold outside today’ to me; she is trying to send me the message that they will break into my apartment and implant the device.”
Emotional reasoning
“It felt like the guy on the street was sending me messages; therefore I am in danger.”
Mental Filter/Disqualifying the Positive
“I did have a good meeting with the supported employment staff, they probably just felt bad for me though.”
Personalization
“Clerk walked quickly down the aisle when he passed me indicating that he knows who I am and what I did.”