Cognitive Behavioral Therapy for Psychosis (CBTp)- Laura Tully, Ph.D.

Morning everyone my name is Dr. Laura
Tully. I’m a clinical psychologist by training, I’m the director of clinical
training at the UC Davis early psychosis programs, the clinics that Dr. Niendam was
talking about this morning and one of the things that I’m very passionate
about and that I provide training for in our clinics is the conducting of
cognitive behavioral therapy for individuals that are experiencing
psychosis. So who here either practices CBT or has received it or done some of
it with their own family? So a few of you. Okay so we’ve got some familiarity with
the model in general. Who here is done it in the context of individuals
experiencing psychosis? A couple of hands. Excellent, okay great.
So what I’m gonna go through today is I’m gonna give just a very quick
refresher of some of the core CBT basics. So for those of you that are familiar
with the model this will be a nice reminder and for those of you that might
not be as familiar this will be a sort of foundation of education as we move
forward to talk about applying it to psychosis and that’s what we’ll talk
about for the second piece. And then I’m gonna spend a little bit of time talking
about how to address negative symptoms which I think are particularly
challenging for some individuals and families and I’m also going to finish
off talking a little bit about the importance of homework in CBT. Okay so
let’s do a quick review. So the cognitive model– how we think about a situation
affects how we feel and how we behave. Nice and simple. So it’s linking our
thoughts, feelings, and emotions. And you can see and hopefully for many of you
this triangle is familiar. It’s pretty common in you know
introductory psychology textbooks pretty common if you’re receiving therapy or
even trying to educate yourself. I think a couple of important things here is
that you see that the arrows go in multiple directions, so there’s an
interaction between these things. It’s not a single direction, it doesn’t just
go linear between your thoughts, your feelings, and behaviors they all sort of
come in a circle. In my experience this model is best illustrated by
something called a thought record. So those of you that practice
CBT or have done this before might be familiar with this structure. It’s a
way of examining and separating out thoughts feelings and behaviors in
response to a particular situation or experience. And I actually do this what
we’re about to do together with my clients in the room as a way of
demonstrating the connection between these three elements. So let’s start off
with a pretty common situation this happened to me actually just the other
day. I was walking down the street I saw my friend Jane she was on the other side
of the street I waved at her to say hi and she didn’t wave back. So what are
some thoughts that I might have in response to that situation? So put your
hand up if you might think that Jane doesn’t like you you. You might think that? I
would think that. Yeah, anybody else? No, Okay over there yeah. So if you thought
that your friend Jane didn’t like you you might feel sad right. What might you
then do the next time you see Jane or just the next time you see another
friend? You might avoid Jane or reduce your social activities because you feel
sad about the fact that your friend doesn’t like you. It’s a little
simplistic but it shows you the sort of linear connection between those things.
Put your hand up if you might think that Jane is mad at you? A couple of you, yeah?
This is another go-to thought of mine as well, I typically believe, and Dr. Niendam
is nodding in the front, she knows me very well,
I typically believe that when people don’t talk to me it means they must have
you know they must be angry at me for some reason and that makes me worried
makes me anxious makes me frightened and then what do I do the next time I see
Jane? I might ask her if she’s mad at me. What impact might that have on my
friendship with Jane if every time I see her I check in about whether she likes
me or not? Whether she’s mad at me? Is that gonna make my friendship better
with her? Is she gonna want to hang out with me? Probably not, right. I’m gonna be
that person that’s constantly seeking reassurance. Put your hand up if you
would just be like, Oh, Jane didn’t see me. Lots of you, yeah, pretty common thought
here. And how do you feel? Probably neutral, maybe you don’t even acknowledge
it you just sort of keep moving on and so the next time you see her you might
be like hey so you’re walking down the street the other day what’s up and
that’s it. So same situation, three completely different thoughts, three completely
different emotional experiences, three completely different behaviors. So this
is a really nice demonstration of the cognitive model. How we think about a
situation affects how we feel about it and how we behave. It’s not the situation
that’s causing the distress it’s the way we’re interpreting it. Now the good news
about that is that we have control over the way we think about things. We have
very little control over our environment around us, but we do have control about
how we interpret it. And this is a good thing because it means when you’re
trying to figure out how to feel better how to manage some of those intrusive
thoughts that you might experience as part of your mental health challenges it
gives you some power and that is the key to CBT. I want to go through some of the
core characteristics and that really distinguish CBT from other treatments.
It’s collaborative, it’s a collaborative project between the clinician and the
client. And what I mean by collaborative is that I come in with expertise as a
clinician right so I have expertise in CBT and how to teach it and how to sort
of apply those rules but the client comes in with expertise in their
experiences, their life, their thoughts, their feelings, their emotions. We bring
those two expertises together and that’s how we move forward in treatment.
It’s not directive. I’m not sitting there teaching you what to do I’m not telling
you what to do. We need to work together to move towards your goals. Its
structured and active. This is not a therapy that you come in and sit down on
a couch and sort of just free talk. There are therapies for that and if that’s a
good fit for you, follow it. But if you’re looking for a structured way of moving
towards your goals CBT is a good option. And it’s active. You as a client and you
as a clinician have to work in CBT. The clinician has to plan for the session,
the client has homework to do, has planning as well, it’s very active and
engaging. It’s empirical in approach. What do I mean by empirical? I mean we approach
it as little scientist detectives. We’re trying to collect data,
collect information about your experiences, about how you think about
those experiences, about the frequency of those experiences, and we use that data
to inform how we approach treatment. It’s also empirical in that we take regular
moments to check in on our treatment to see if it’s working. Is the client
feeling better? Are their symptoms reducing over time as a consequence of
the interventions that we’re choosing together? If they’re not we need to
change what we’re doing. It’s ethical to make sure that what I’m doing as a
clinician with my client is actually working.
It’s problem-oriented that means that we work together as client-clinician
collaboration to identify the problems that might be contributing to distress
in the clients life and then we tackle that problem, right. Which means that it’s based in the now and I’m gonna talk a little bit about that in a second.
We use something called guided discovery and Socratic questioning that’s a way to
kind of draw the client towards an answer that they might already know and
it’s just about guiding that discovery. We use a lot of behavioral methods by
behavioral, I mean active. We go out and test things out we do experiments we
gather data. It’s not just sitting in the office talking. And we do at the end of
every session a lot of summaries and feedback. So as a clinician I’ll provide
a summary of what we discussed today and then I’ll ask you as a client to tell me,
how did that go? What was good for you in this? What jumped out for you in
this session? What could we do better next time that would fit your goals and
your needs better? And we’re doing this sort of iterative process together each
session. And that comes back to this empirical approach, right, making sure
that what we’re doing is working and fitting the client. Structure of CBT
sessions– as I said they’re very structured. For those of you that are
practitioners and are interested in implementing this or tweaking your own
style if there’s one thing that you walk away with today I want you to walk away
with the importance of setting an agenda. You do it at the beginning of every
session, you plan it out and you stick to it. So here if you don’t know how to set
the agenda I’m gonna give you one and you can use this rubric in all of your
practice. So you start off by setting the agenda, it takes one to two minutes then
you’re gonna do a homework review it’s important to do this your client has
worked hard to complete the work that you’ve discussed together, you need to go
over it and reinforce that. Then you’re gonna cover what I call the clinician
item so this is what I’m bringing in and it’s part of my overarching plan for the
client and I to work on, part of our treatment goals. And I typically allow
about 15 minutes for this and included in that is the homework setting for next
week. So the homework should really be based on your what you’re doing in
session that day and it should connect from week to week, or from session to
session depending on how frequently you’re seeing each other. Then you have
the client item. So the client gets to generate what they want to bring in and
over time you’re working towards structuring it so that the client and
clinician item are actually pretty close together, because you’ve got this sort of
theme. It’s important to give this time because it’s collaborative and as a
clinician you have things you need to cover. There’s psychoeducation to do there’s
exercises to do there’s information to collect and as a client you have things
you want to talk about. It’s important to give each of you your time. Then you
solicit feedback and you’re done. Note how quick this is. I typically write this
on a board in a visual place so that my clients and I can see it. Sometimes we
set timers so that we can respect each other’s time. You’ll note that the
clinician item comes first in this agenda depending on the fit for your
client you could if it’s better if it’s more motivating for them to go first you
can you can flip that. It’s important that you make sure you get to both, okay. The second thing if you have the
capacity to take home two things from my talk today that I want you to take home
is the three C’s: catch it, check it, change it. This is the structure that
should carry you through your CBT work with your clients and your clinicians.
And essentially you’re working to identify, evaluate, and reframe what we
term distorted cognitions or inaccurate thoughts about situations related to
identify problems. You’re going to use both cognitive and behavioral techniques.
So cognitive techniques are typically examining the thoughts that
somebody has about something, so it’s more discussion based, you might have
some worksheets. That thought record that we did together
that’s a cognitive technique. But you can also use behavioral techniques. So this
is going out into the world and actually testing things out, doing behavioral
experiments. And what that looks like is you might have a hypothesis, you might
have a prediction, so typically whilst doing a thought
record my clients will say to me well if I do that then this will happen. That’s a
prediction, you can test that. You can go out into the world and you can test
whether it’s true or not. That’s a behavioral technique. And, you’re
going to base all of these things on your what we call the CBT case
formulation or CBT case conceptualization that you have
generated together. And I’m going to tell you a little bit about what that is
right now. So a CBT case conceptualization is a way to understand
what the current problem is that the client might be experiencing, an account
of why and how these problems developed, and an analysis of processes that
maintain the problem (ie keep it going). And it’s actually this last point this
identification of maintenance processes that’s going to inform your intervention
choices as a client-clinician team. And the reason for that is that maintenance
processes are sometimes different from the thing that started the problem in
the first place, right, but they’re the thing that’s keeping it going. And so if
you’re trying to stop the problem, you’ve got to stop the thing that’s keeping it
going. A clear example could be you know perhaps you have a client that has
comorbid trauma symptoms and psychosis symptoms so they might have had
childhood trauma and then later on as an adult they’ve developed auditory
hallucinations the content of which is related to that trauma and these
auditory hallucinations are being maintained by some level of avoidant
social avoidance. It’s really hard for you to address that trauma directly
in order to get rid of the auditory hallucinations using CBT for psychosis
there are other ways to do it and we’ll talk about that later.
The thing that’s maintaining those auditory hallucinations
is probably the social avoidance so let’s address that. And here’s the
sort of simple rule for this, if you want to put out a fire you need to tackle the
elements that are keeping the fire going like heat fuel and oxygen rather than
look for the spark that started the fire. Okay, that doesn’t mean that CBT doesn’t
care about the past, it does, but your intervention choices are going to be
built on trying to put out the fire. Once you’ve got the fire out you can talk
about what caused it so that you can prevent it from happening again.
So does that make sense in terms of the order of what you’re focusing on? This is
an example worksheet that I use for my case conceptualizations with my clients.
We do this together in session and I’m just going to do a quick review of what
they are. So right in the center here we might describe the problem. So if we put
in depressed mood and social isolation, that might be a problem that the client
wants to work on. And the triggers are modifiers, these are things that make a
trigger is something that makes a problem more likely to happen, and a
modifier is something that makes the problem better or worse. So a modifier
for a depressed mood typically is sort of physical modifiers like sleep, food,
medication, right. If I get a good amount of sleep I’m less likely to be depressed
if I get less sleep or too much sleep I might be more depressed.
That’s a modifier. And then a trigger for depressed mood could be having an
argument with my partner and that might make me sad and then make it worse. Precipitants– these are things an event
that has happened that happened just before the problem and then sort of a
part of the causal pathway. So we know from research that you know a
significant life event like the ending of a significant relationship can be a
precipitant to the development of depression, right. So that would go up
here. And then up here’s our vulnerability factors. So this harks
back to what Dr. Niendam was talking about. So you might put genetic factors up here,
you might put a childhood events up here, prenatal events. So in terms of
depression we know that the loss of a parent in childhood
makes you more vulnerable for the development of depression in adulthood,
so we would put that up here as a vulnerability factor, and that this then
might contribute to the beliefs that we have about relationships in the world. So
I might have developed beliefs around people that love me tend to leave me
which might make me unlovable I might develop an unlovable belief, which is
fairly common trajectory for people that have experienced loss early on. And this
then contributes to the thoughts, feelings, and behaviors that I have in
the context of my depression. Does that flow make sense to people? I’m seeing
some nodding, that’s good, okay. And then we have our maintenance factors, so
things that are keeping the problem going. So typically in depression when
we’re sad, when we’re depressed, when we have low mood, what do we do? We stay home, we
isolate, we sit, we binge watch a Netflix season, right? And what happens is
with that social isolation is that it means that we don’t get a whole ton of
positive experiences, which means we never get new data to challenge the idea
that we’re sad and alone, and so this social isolation, this avoidance, this
staying at home becomes a maintenance factor of our depressed mood. Does that make
sense? So what then is the intervention? Anybody want to shout it out? Say it
louder for me. Behavioral activation, getting out, maybe getting some more
social experiences or some positive experiences and then you get more data
to show that actually perhaps the world isn’t as lonely and as sad as you
thought and to start challenging some of those cognitions that you had around the
beliefs around yourself, the world, and others. So it’s a nice case
conceptualization. And as I said I actually pull this worksheet out and we
fill it out together and you can you can fill this out for the client as a
whole but that’s kind of complicated or you can fill it out for specific
problems that you and the client are working on– depressed mood, auditory
hallucinations, trauma, etc. Common maintenance processes are listed here.
Safety behaviors and avoidance– this is the most common, we do this all the time.
If something is frightening what do we do? Wed try and avoid that frightening
thing. In many ways that’s adaptive, but in some ways it can then maintain
anxiety symptoms. Reduction of activity– we just talked about that for depression.
Right, I feel sad, I have low mood, I have low energy so I just sit on my couch
which then contributes to me feeling sad and having low mood and having low
energy so I sit on my couch which contributes to me and you know and on
and on ad infinitum. Catastrophic misinterpretation– so this is
particularly relevant to feelings of panic disorder and physiological anxiety.
So perhaps I have a heart flutter or my palms get sweaty and I might interpret
that as a sign of danger like my body’s in danger like perhaps I’m gonna have a
heart attack perhaps I’m gonna die and then if I believe that I get into this
negative spiral and then I have a panic attack, that’s what a catastrophic
misinterpretation is. Self-fulfilling prophecies– if I go to the party people
will think I’m boring and then I won’t have any friends so what do I do I don’t
go to the party nobody ever realizes how wonderfully
exciting I am then people think that I’m boring and I never get invited to
another party again this is a self-fulfilling prophecy, right.
Performance anxiety– I had this this morning. I had to give a talk to a group
of people it’s gonna make me kind of sweaty and uncomfortable what if I make
a fool of myself I kind of don’t want to give a talk which means I never learned
that actually it’s okay. So here I am doing exposure, learning that this isn’t
as frightening as I thought it was. Fear of fear is another maintenance factor and
this is a slippery one. This is a fear of being frightened. Now typically this
develops out of individuals who experience a lot of anxiety and it’s
physiological very physiological and very aversive to feel anxious. Those of
you that have experienced this kind of anxiety will know what I mean it’s very
uncomfortable, you feel very jittery your heart is always a little bit fluttery
and you feel like you feel like you’re on edge the whole time and that’s a
really aversive experience and so you do everything you can to stop yourself
from feeling anxious which ultimately means that you may just end up sitting
on the couch and not moving because moving makes you anxious. Perfectionism–
another one you try to do things so perfectly that you never get things done,
which means that you never finish it, which means it’s never perfect which
means you’ve never achieved your goal. And then the last one is short-term
rewards. This is one that I see a in our clients. So a short-term reward is
something that makes you feel better in the moment but in the long run makes it
worse. So there are two really clear examples
of this: substance use and a non-suicidal self-injury. So substance use is hard as
a clinician to work with your clients because in the moment it really works it
makes people feel better. If you’re socially anxious and drinking relaxes
you even though it gives you a hangover and makes your symptoms worse the next
day, you’re still probably going to do it in a social situation because it in the
short term rewards you and makes you feel better.
Same thing with non-suicidal self-injury. If you’re feeling very very emotionally
disregulated or out of your body or distressed and hurting yourself pulls
you out of that and can make you feel better it’s really hard to stop that. So
the trick with short term rewards is that you want to add a replacement
behavior. Just telling someone to stop drinking when they’re anxious probably
isn’t gonna work because they’re just gonna get more anxious and they’re
going to look for another behavior to make them feel better and they won’t
have the skill, so you need to replace it. Same thing with substance use you need
to find a replacement behavior that gives the same reward with long-term
benefits. That’s our quick CBT review. Any questions? Yes. Yes, and typically we work on sort of
discovering that together by collecting data. So the first step is just to track
over time how the substance used makes them feel just so we can evaluate
whether it’s actually working for them or not. So typically my client will say I
smoke weed because it makes me feel better and I’m not going to stop. And I
say okay well that’s just let’s just track that over time and we find out
typically from the data that in the moment it makes them feel better but the
next few days they have more symptoms and they’re able to look at that data
and be like oh yeah I see and then we test out other things together. So it
might be can we develop a you know first what is the function of the substance
use in that moment for you and can we develop something that has a better
function? So for some of my clients it’s just the effect of fidgeting and so we
give them something else to do with their hands. For some of them it’s
removing them from a situation where substance use is the center of it and
getting them an alternate social situation, which can take a lot of work.
So those are two really common examples and there are others, but I think the
most important response to your question is that you have to discover that with
the client, because if you’re just telling them that it doesn’t work. They
have to figure out what works for them and your role as the clinician is to be
the person guiding them through that discovery process, right. Good question.
Okay let’s talk about how we can apply CBT for individuals that are
experiencing psychotic symptoms. So there we go. So typically psychosis is
traditionally defined and by psychosis I’m pretty much talking about
positive symptoms, right, so hallucinations and unusual thinking
delusional thoughts. It’s traditionally discussed as this
difficulty distinguishing what is real from what is not real, right. And the
typical definition that we give is this idea of what a delusion is it’s this
fixed false belief held in the face of contrary evidence and it’s seen as
really different from other kinds of mental health challenges, right. But
riddle me this. In depression, when someone is really depressed
they have fixed distorted beliefs about their own self-worth and efficacy and
for those of you that have worked with individuals that are very very depressed
or for those of you that have experienced depression this is true. It
is hard to convince yourself otherwise that those negative thoughts that you
have as part of your depressed mood aren’t necessarily accurate, even in the
face of contrary evidence. In anorexia nervosa really severe eating disorder
it’s characterized by a fixed false belief around being overweight, even in
the face of contrary evidence. You can have an individual who is dangerously
underweight on a scale you can show them the BMI data you can even have them draw
an outline around their body and step a way to look at it and they will still
say when they’re in that episode when they’re really in the phase of illness
I am overweight. This is not true. My experience of being overweight is true.
It’s a fixed false belief in the face of contrary evidence. In panic disorder in
that moment of your panic attack you are convinced you’re gonna die, absolutely
convinced, and trying to tell that person otherwise isn’t particularly effective.
It’s a fixed false belief in the face of contrary evidence. And then in OCD we see
a lot of distorted beliefs around what we call thought-action fusion. If I have
the thought that I might hurt my partner then it means I will hurt my partner and
this is even in the face of evidence showing that thinking and doing are
different, the individual still holds this belief very tenaciously and
it’s part of the illness. It’s a fixed false belief in the face of contrary
evidence. So what’s the difference between these things and psychosis? The difference is that typically psychosis
beliefs are characterized by culturally unacceptable ideas or interpretations of
our experiences. So if you have a young woman who discovers a lump in her breast.
Let’s say you have three young women they each discover a lump in their
breast, one of them says hmmm this could be breast cancer I’m gonna go check it
out with my doctor. You get a biopsy it’s benign it’s fine they’re like okay, glad
I got it checked. The second one says oh my god this could be cancer I’m gonna go
check it with my doctor they have multiple tests and even though
those tests show that it’s benign they don’t believe them they’re like no
there’s definitely something wrong with me this is a feature of hypochondriasis
right as well as somatic delusions. And the third one says I have a lump in my
breast it must be a radio transmitter from the government listening to my
thoughts. Same situation, three different interpretations. Two of which are
inaccurate but one of which is culturally unacceptable and so we say
it’s psychosis. This is stigmatizing and distressing for
the individual that experiences it and that might maintain the psychosis in the
first place. So the implications for this, for thinking about the fact that
psychosis beliefs and other beliefs in other mental health challenges might
just all be distorted cognitions means that first of all if we can
normalize that sometimes our brain tricks us and gives us thoughts that
aren’t accurate that might reduce the stigma and distress. So just doing
psychoeducation around the nature of thoughts how they can be random and
intrusive but not always accurate that can improve things. And then, the logic
here is that CBT techniques that can be used for depression, anxiety, eating
disorders, which we know to be effective, might also be successful in psychosis as
well. And that’s indeed what the evidence suggests plenty of randomized control
trials support this. Hopefully as a practitioner you’re looking at this and
you’re like oh I can apply cognitive techniques to psychosis beliefs how
exciting. We’re quickly going to take a moment to do the what the sort of
empirical model of this is. So I talked about this culturally unacceptable
interpretation of experiences. Why does that happen for individuals with
psychosis versus individuals with depression? And the answer is partially
explained by something called the self- regulatory executive functioning model.
So you heard this morning about the frontal lobe deficits for individuals
that experience psychosis and the difficulties in what we call executive
functioning, and so that’s really important here. So
first of all we conceptualize psychotic symptoms: auditory hallucinations, etc.,
delusional thoughts, as intrusions on your consciousness and cognitive
impairments, particularly those in the executive functioning realm, contribute
to the salience of these intrusive experiences. So the idea here is that we all have intrusive thoughts, but some of us our brains are better at
inhibiting those or sort of sorting them out as not necessary to pay attention to,
and some of us have a hard time inhibiting those and not paying
attention to them. And it’s that executive functioning piece that helps
us decide whether we’re going to pay attention to something or not and so if
you have impaired executive functioning it might be harder to do that. And then
relatedly this idea of metacognitive beliefs and by metacognitive I mean our
beliefs about our beliefs so our thinking about our thinking. So if I had
a thought that somebody was following me from my car and then I had a thought
about that thought oh my gosh I must be mad I must be going crazy
that could cause distress and then you have this sort of iterative spiral of
unusual thinking. And again it’s the interpretation of these intrusions that
distinguishes individuals with psychosis from other diagnoses. So
if I had thought that someone was following me from my car today and I had
said ah I’m just imagining it and kept walking that’s a really different
outcome from me than changing my route from my car or perhaps refusing to get
out of my car. Right, so again, it’s the interpretation of that intrusive thought
that separates the psychosis style thinking from other mental health
challenges. And I’m going to be better able to evaluate that interpretation if
I have good executive functioning. So I’m going to go through a couple of the
theories of auditory hallucinations and delusions so that with a couple of
practical tips for how you might be able to apply this. So the idea is that
auditory hallucinations are actually miss attributed internal mental events
so this idea of your own verbal thoughts or inner speech. So most of us tend to
have an inner monologue right most of us typically experience it as verbal
sentences some of us have more visual inner monologues images it’s the same
idea and the idea in psychosis is that individuals with psychosis have a harder
time telling where a thought came from and that’s going to be related to those
executive functioning things. Was it my thought or did it come from outside? And
then when it gets into an episode it’s this idea that actually this thought
that I had it’s a voice I’m hearing it coming from the outside. There’s some
evidence to suggest that to support this idea so individuals with psychosis are
less likely to recognize their thoughts as their own if you have them write down
a selection of thoughts and then you jumble them up with some other thought
other statements that they didn’t generate they’re less likely to be
able to say I thought this but I didn’t think this. They’re less likely to
recognize their own voice playback with minor distortions compared to
individuals that do not experience psychosis and they tend to assume that
ambiguously sourced information was generated externally. So it’s this idea of there being a blur or a confusion about what’s what’s mine and
what’s outside of me. So here’s an example. So I might have difficulty
identifying where the stimulus or the thought came from so then I might assume
that it came from outside the self this then triggers negative automatic
thoughts, that’s what NATs mean here, about my state of mind so I might be
like oh I’m going I can’t believe I just heard a voice I must be crazy this
triggers anxiety and fear which then triggers my efforts to reduce my anxiety
so my behavior so I might put headphones on I might refuse to go outside I might
refuse to go into crowded areas because it’s distressing because and then I’m
trying to reduce my anxiety. So in this situation you can use your CBT model
intervention techniques to get at the thoughts and break that maintenance
cycle. Another way of thinking about auditory hallucinations is that they
might contain content they might be statements that conflict with how I
think about myself. So for a lot of the clients that I work
with, the content of the auditory hallucinations that they have
contain distressing, violent, or overtly sexual thoughts that are unpleasant for
them to experience. They might clash with who they believe themselves to be. And they don’t match with the belief about themselves. So perhaps I have a sort of intrusive thought about a violent act
against a family member, but I don’t I love my family I don’t want to be
aggressive or violent towards them that can’t be my thought it must have come
from somewhere else and so then perhaps I interpret it as a voice or a thought
that’s been inserted in my own head, and here’s the pattern. Okay I’m gonna move
forward a little faster. Okay so this links me to the CBT theory of
delusional thoughts as well. So the first thing to know is that some delusional
ideation might actually be an attempt at rationalizing anomalous perceptual
experiences, right. So that example of having perhaps sort of thinking I’m
hearing a voice or thinking I’m hearing some whispers but I don’t know where
it’s coming from and it doesn’t make any sense and so perhaps I say it must be a
ghost talking to me, right. It must be God communicating with me even though
perhaps I’m not a religious person. Or it could be a culturally unacceptable
explanation for life events and then it becomes this delusional
piece. It’s typically thought to be the result of a rapid overconfident
reasoning style so a lot of the research has shown this to be the case in
individuals with psychosis that they tend to get to their conclusion faster and
are very confident about it. They’re more likely to jump to conclusions but more
willing to change hypotheses with new information. So the good news about that
is is that you might benefit from working with your clients on learning
how to evaluate competing hypotheses about things. So that’s kind of the catch
it, check it, change it piece. Can you catch the ideation, check its
accuracy, is there an opportunity to reframe or generate an alternative
of explanation? And so hopefully you know where I keep sort of hitting on
today is this idea of the interpretation of the experience is really important. That’s the thing that causes the distress and the behavior so you’ve got
to get atwhat that interpretation is with your client. So an example here is
you might experience an intrusive or unusual thought that people are talking
about you behind your back and one interpretation might be it’s my
imagination I’m just tired and stressed so perhaps I go get some sleep and I
reduce my stress and shrug it off or another interpretation is those people
are trying they’re plotting to hurt me they’re trying to trying to do something
against me which then triggers hyper-vigilance for other instances and
perhaps the adoption of safety behaviors like avoiding people carrying a weapon,
those sorts of things. Again the interpretation here is really key. Also
this is an opportunity for me to emphasize that CBT is not just about
positive thinking it’s about realistic thinking. So sometimes people do talk
about us behind our back, that happens all the time. The question is what does that mean for me? How do I choose to interpret that? How
do I choose to feel about it and then behave about it? So it’s not just
about positive thinking it’s about realistic thinking it’s about being able
to evaluate the way you’re thinking about a situation and coming up with an
adaptive interpretation. Okay some general tips. Psychoeducation and
normalization of the experience is key. Actually, a lot of people experience
perceptual abnormalities depending on the study that you read anywhere between
25 and 50 percent of people in the general population will say that they
have experienced a psychotic like experience. And I have a funny feeling
that Dr. Niendam talked about this this morning. Normalize that this is
actually pretty common and it’s how we interpret it that’s going to make an
impact. Always place it in the context, whatever
you’re doing, always place it in the context of your case conceptualization.
What are the triggers? What are the modifiers? What are the maintenance
factors? So that means you might spend a good portion of the first part of your
treatment just collecting on those things, just evaluating what’s
going on. Don’t rush to get to the thought record. Spend the time to get to
know the problem and build a conceptualization. Use guided discovery.
Simply telling the client that they are wrong about their delusional belief is
not going to change the belief. It’s also kind of unfair. And then note that the
process causing the distress might not be the psychotic symptom itself. So I think a lot of the time as clinicians we’re so focused on the
positive symptoms that we might miss that there are other things happening
for the client that are more distressing. I have plenty of kids in school that
hear voices pretty frequently and they’re able to kind of get through it
and the thing that’s bothering them is actually their anxiety in social
situations, so let’s pay attention to that. Some specific tips in terms of
applying CBT to psychosis. You can put the symptom as the situation in your
thought record. So in the catch it phase you’re going to then identify
interpretations of that symptoms or the resulting feelings and behaviors. So perhaps the situation might be I’m sitting in math class and I start
hearing voices. That’s your situation. Now what am I thinking? Oh no, my symptoms are
coming back again. People are gonna look at me. I’m not gonna be able to succeed
in math class, I might as well leave. I should just quit school. I’m really
frightened and I go home. So that’s an example of putting the
symptom as the situation and how you’re interpreting that experience. Evaluate
the accuracy of the thought– evidence for and against, patterns of distortion, and
then if appropriate, generate an alternate explanation or a more adaptive
thought around it. You can normalize here too. Of course it would be stressful to
start having auditory hallucinations during your math class. It’s gonna make it
really hard to concentrate. That’s okay. Can we take a minute to do something to
reduce that distress so that you can return to class? Here’s an example of
different interpretations for experiencing auditory hallucinations
from a client. One interpretation is that perhaps is a higher power for
example God talking to me. The evidence for this is that the voice seems to
predict unlikely things happening. I have this imagery of a higher power as part
of it and there’s a physical feeling it feels really powerful these voices feel
really powerful and it’s actually a really common thing that my clients will
tell me. But the evidence against this is that the prediction could be a
coincidence and there’s a lot of what the voices predict don’t actually occur.
Okay. It could be a sign of illness. Evidence for this is that it can be
associated with elevated mood for this particular client and it
can be triggered by paranoid ideation. Evidence against this is it doesn’t seem
to happen at work so if I was ill all the time wouldn’t it happen everywhere
and it’s different to elevated mood. So this is an individual with a bipolar one
diagnosis just as a background. And another interpretation is that it’s just
an unusual thought process that happens. Evidence for this is it could be a
stress response it can be triggered by cannabis and then what what the voices
seem to talk about is similar to what I think about and then evidence against
this is that it feels really real. So things to note about this evidence for
and against chart is that it the right answer doesn’t jump out immediately,
right, and that’s because sometimes there isn’t a right answer what you’re working
with on this with your client is just this technique of evaluation and
exploration. If the client has the opportunity to generate alternate
possibilities for that experience it could contribute to the reduction of
distress from that experience. Practical tip number two: put the content of the
symptom as the thought in your thought record. This is particularly good for
auditory hallucinations but you can do it with delusional ideation as well. So
then evaluate the content. So perhaps very common for our clients is that the
content of their auditory hallucinations are sort of cruel negative statements
like: you’re gonna fail, you’re a bad person, nobody likes you, everybody hates
you, etc. Actually these things are really similar to the kinds of negative
automatic thoughts that individuals with anxiety and depression experience. So if
you place the content like what voices are saying in the thought column
you may be better equipped to start evaluating how accurate that content is.
Is it true? What’s the evidence for the idea that nobody likes you or
that everybody hates you? What’s the evidence against that? Can we come up
with a response a comeback thought to this idea? A couple of notes here when
you’re doing the check it phase and you’re doing the evidence for and
against– I strongly recommend doing evidence for first. It’s often easier for
individuals to do that and it’s sort of reinforcing and empowering to allow that
discussion to happen. Again, coming back to this idea that individuals with
psychosis may have had a lot of people telling them that they’re just wrong and
delusional which is really stigmatizing it’s really demotivating. So start with
the evidence for then move to the evidence against typically it’s more
successful. Practical tip number three– focus on reducing conviction. So the goal
might not be to remove the distorted belief entirely, reduction of conviction
can be extremely helpful. This is going hand-in-hand with the generation of
alternate explanations. See how each explanation that you can generate
together reduces that conviction level. So by conviction level I mean like what
percentage convinced are you that people are indeed out to hurt you? Are you
100% convinced? 90% convinced? 80% convinced? Okay let’s go do a
behavioral experiment. Let’s test out your prediction. Let’s see what the
results of that experiment tell us. Has it changed our conviction in this belief?
Can we generate an alternate belief? And if you can just bring that conviction
down that can be very impactful. Something called the pie chart technique
can be helpful here. So you just draw a big pie and you portion out the pieces that
reflect the percentage of belief that you have for each of your explanations
it can be really nice. Finally some cognition some delusional
ideations aren’t particularly well-suited for a check it phase for an
evaluation of evidence for and against. It might just be really they might be
slippery it might be hard to generate a if evidence against or for something and
it might be better to approach it from a pros and cons perspective, because
evaluating it might just cause more distress. So evaluate the pros and cons
of just holding that belief or acting on that belief. So an example could be an errotimanic belief so a client that might be convinced that they have a
secret love affair with a very famous person that they’ve never met and
they’re very convinced about this. That’s super hard to evaluate evidence for and
against and it can cause a lot of distress. But you could evaluate the pros
and cons of acting on this belief how is that impacting your relationships in
your current life, how is it impacting your goals, what are the pros what are
the cons, can we sort of just put that belief in a box and then go about our
daily business? So it’s a really different approach from trying to get
rid of the belief. Always review the pros first. Okay, promote internally generated
explanations could the voices be your own thoughts how can we test this
psychoeducation is really important here so talking about this idea that in
psychosis because of those executive functioning deficits it can be hard to
tell where something came from did it come from me or outside of me. Provide
that education and then then work on developing the skills to determine
whether that’s the case or not. Behavioral experiments are really really
useful here so that if I do X then Y will happen then go test it. If-then statement this is your bread and butter as a behavioral experiment
clinician. So a big piece of CBT is doing is the client doing what we call
homework in between sessions. And I just want to dispel the idea now that
homework enhances therapy. Actually, therapy should be enhancing homework. We
get to see our clients for what 45 to 50 minutes once a week, if that? Sometimes
it’s every other week. It would be very arrogant of us to suggest that we
can change someone’s whole life when we spend 45 minutes with them, right.
Actually the change has to happen outside of therapy and we get to just
sort of gently enhance that and encourage it in therapy. So it’s
really important that you as the clinician and as
client understand the rationale for homework and you have to get this done
at the beginning of therapy. You cannot introduce homework halfway through when
you haven’t been doing it. It’s really hard. So, first of all, beliefs and
distorted cognitions rarely change through discussion alone. You have to go
out and try something new you have to do something behavioral you have to test
out a new cognition. That’s got to happen outside of therapy. I’ve talked
about this already, therapy session is really only a brief
portion of an individual’s life what happens outside of session is more
important. If an individual is completing the homework assignments, doing the
practice, observing the change, it really gives you a sense of achievement. I know
this both as a student who does homework but also as an individual that’s gone
through therapy and has realized that I get more out of it when I get to do the
homework. And then you can use the homework successes or the data that
you collect through that as linear evidence for the progress over the
course of therapy. And just to kind of back this up with some empirical data,
in schizophrenia spectrum disorders, treatment that includes homework results
in 60% more improvement in symptoms than treatment without homework. That’s a
whopping number, so please include homework. Types of homework– there are
three: information collection, experiments, the practice of new skills. The first
part of your treatment with your work with your client is going to be a lot of
information collection; tracking symptoms, current symptoms, current functionings,
substance abuse, etc. Really just trying to get to know the problem that’s going
to feed into your case conceptualization so that you can develop experiments
which can find you know develop new cognitions and then perhaps indicate new
skills. So actually these things are going to go probably in a linear
trajectory over the course of your treatment. What to choose for homework–
there’s a nice rubric the 3 R’s. Is it relevant, is it realistic, and is it the
clients responsibility? Don’t give your client something to do that they don’t
have the power to change or that isn’t their responsibility to
change. Make it realistic and achievable, don’t set them up to fill out
five thought records a day for the next seven days when you know that that’s
probably not going to be possible. I couldn’t do that, it’d be really hard for me to remember it. And make it relevant to what
you did in session to the model to the case conceptualization and to the
clients goals. How to choose it– do it collaboratively. It is not the client
deciding alone and it is not the clinician telling the client what to do.
If the client isn’t able to generate the ideas really talk about the 3 R’s
together. Figure out if there are barriers to even understanding or doing
the homework, make sure that the client understands the session content,
understanding the rationale for homework and vice-versa. Through some of these
conversations you might discover that you missed the point as a clinician and
you kind of have to go back and redesign things as well. If it’s really hard to
generate a particular task work with the client for them to do something over the
course of that week to engage in something, if it’s just tracking the
symptoms this is worthwhile. Increasing homework compliance– you could call it
practice. Make sure the client understands. Allow enough time on your
agenda that I know you’re all going to set after today as part of your
treatment to decide on the homework, do not leave 30 seconds to be like okay
cool and do a thought record that’s not going to work. Check for understanding. Problem solve
ahead of time for things that could get in the way if this individual has a hard
time remembering do they need to write stuff down if they don’t have access to
the materials that they need to do the homework or they can’t you know perhaps
you set up a task to go to a Starbucks to test something out what if they don’t
have a Starbucks near their house maybe they don’t have transport problem solve
ahead of time. Design the homework so that it’s realistic, provide the
necessary materials, and involve family and support networks to help doing this.
Don’t leave the client on their own to do it if possible. Remember that the
family can act as that frontal lobe they can help, so involve them. And I’ll finish
on sort of a slightly tongue-in-cheek response for common reasons why homework
is not done. Perhaps the clinician has failed to work with the client to
provide a clear understanding of why homework is important. The therapist
might leave 30 seconds at the end of the session to assign homework. Therapist
doesn’t include homework setting on the agenda.
You might assign homework without figuring out the implementation of it, or
perhaps you’re really directive about it it’s not collaborative and so the client
doesn’t really have buy-in into doing this task. So actually the onus is really
on the clinician in doing a really good job on this. If a client doesn’t do
homework you must find out why do not sail past this. This is going to be the
content of your session, probably. Do not just shrug and move past it. Be prepared
for problem solving to take the majority of your session. Be curious and not
confrontational. The reason it might not have got done could have been because we
didn’t do a good job setting it up. And if there’s sort of a motivational
issue or an engagement issue you might need to spend some time doing some
motivational interviewing and sort of value examination. Include the
family. Okay, I think I’m a little over but here are the take-home messages. A
detailed case conceptualization is essential for effective CBT. Use your
three C’s to guide your treatment. A couple of tips: place your psychotic
symptoms as situations or thoughts in the cognitive model. One of the things
that I sort of peppered throughout and that you’ve got from Dr. Niendam as well
and you’ll get through the other talks today is that if you have limited time
with a client just doing psychoeducation and sort of normalization and stigma
reduction it’s a really effective intervention. We didn’t get to talk about
this but just rule of thumb negative symptoms are best addressed with
behavioral techniques. And given that homework is the cornerstone of treatment
if there’s no homework done gains are going to be limited, so just know that. If
you’re working with a client where you’re not able to do homework you have
to work with the idea that the gains are going to be limited.


  1. Dr Laura Tully, you tried to teach the CBT which I enjoyed your delivery but your use of God in your illustration revealed that you are also trying to use what you did not completely grasp as an example. Why I agree that some may think that God is speaking to them, there are people that God indeed talk to. There must be a way to distinguish these in your illustration. if not, you can also include "hallucination about others' hallucination" as a case to be studied.

  2. Very informative and helpful. I would love to see a video about how to tackle the difficulty with starting a client with therapy when we know that clients with psychosis are so reluctant on starting therapy since they generally believe that there's nothing wrong with them. Thank you.

  3. I really wonder how you hope to help those doped people whose cognitive abilities severely impaired? In order to be able to help those people their hippocampi should be active. Hippocampus needs emotions in order to be able to tag the informations to learn. That's how we can learn and keep or record the informatons and knowledge in our brain and process them when we need. Yet, as their emotions are seriously blunted due to the drugs they receive their hippocampi have no avail. Most probably most of your efforts with them completely disappear within a couple of hours time altogether. Psychotherapy programmes with schizophrenics on drugs are doomed to fail.What you say here that you can help those suffering individuals has no scientific basis what so ever. That defies logic and neuroscience.

  4. It's not the same in the example of socially acceptable thoughts. Thinking you have a radio recorder in your body is not the same as thinking you have a lump or cancer.
    Having cancer is possible, having a radio or recorder in your body is not, or is nearly impossible and there would be scars and cuts around it to show that it was inserted.
    I think that's a dishonest example and not a good representation of how stigma plays a part in these scenarios. It also doesn't account for how difficult it is for people who have never interacted with someone experiencing psychosis or living with schizophrenia.

  5. Everything else was great, it's obv you have a lot of experience and know what you're talking about. It would be lovely if one-day academics learn to do a presentation without boring slides with text and constantly reading from them. You would be an amazing presenter without the slides.

  6. I’d love a drug free approach. I get where I need my (NPD) loves to define thing. I may have hallucinated 151/100 episodes except I’m still suicidal, still cannot cope with emotions dumped, and I hurt. Bring on whatever drugs make it stop and allow me to live

  7. I've been in recovery from Sz since 1978 and doing well! I've always used an entrepreneurial approach of moving forward with experiential learning in a self directed way to not only enhance learning but to transform in emotion and behaviour to thoughts or reactions of mine. It seems, I was lucky to learn in therapy what seems to have been CBT without actually having a name for the processes. This experience is very deep seated and transformative. I now don't have voices, hallucinations or delusions. My psychiatrist recently retired and in his discharge said I don't have personality issues or a pathology and no apparent psychosis. I'm euthymic in mood. I'm very grateful to many……….

  8. Thank you Laura for this great presentation on CBT and Psychosis!!!!! You are a wonderful presenter……………

  9. I love the slides, this is how I learn. Having Auditory Processing disorder allows me to pause on the slides and resume when needed. I am working with an individual with schizophrenia, I relate to the transmitter story, this delusion is a common one. They will also see the scar and remember being held down against their will during the injection of the transmitter. This can cause PSTD of a traumatic memory that never happened.

  10. She has a British type accent but uptalks and says things like “riddle me this” which means fcuk all to me.

  11. But what if the person really is the subject of a massive abuse by proxy and harassment campaign? Or what if the person is a subject of experimental technologies such as remote neural monitoring and brain linking technology?

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