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Cognitive-Behavioral Therapy for Psychosis. Demian Rose, MD, PhD Rachel Loewy, PhD. Why CBT?. 1. Because it provides a model of belief that is easily transferable from depression to psychosis to anxiety and back 2. Because it works!. Prodromal Interventions.
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Cognitive-Behavioral Therapy for Psychosis Demian Rose, MD, PhD Rachel Loewy, PhD
Why CBT? 1. Because it provides a model of belief that is easily transferable from depression to psychosis to anxiety and back 2. Because it works!
Prodromal Interventions *Statistically significant difference
Early Ideas about Psychotherapy • Freud • Neurosis = ego’s reality-based suppression of the id • Psychosis = ego’s indulgence of the id
Psychosis Myth #1 • Chronic psychosis is a return to a core, primitive level of brain processing • “psychotic process” • “Psychic Swamp”
Corollary to Psychosis Myth #1 • There is no reason to believe that psychotherapy for people suffering from chronic psychosis has to be fundamentally different from psychotherapy for people suffering from other problems. • The myth of “Supportive Therapy” as the psychotherapy for chronic psychosis
An error in information processing(the character of which depends upon the system in question) Psychosis – A Neuroscience Definition:
CBT Basics • Events or other stimuli trigger: • Thoughts, which trigger: • Emotions • all of which leads to…
CBT Basics • Immediate behavioral responses • Schema activations (Schema = cognitive structure that explains patterns of behavior or events) • Eventual behavioral responses (Thought-Emotion-Behavior Loop)
The CBT Loop Thoughts Emotions Behaviors
CBT Therapist Qualities • Develops shared problems and goals • Identifies strengths and realistic plans, timelines • Educates, educates, educates • Actively questions (“dialectic” a.k.a. “Socratic” or “Columbo” method) • Encourages self-discovery • “homework”
Special Considerations • In Psychosis: • Normalize • Psychotic experiences are actually quite common • Psychotic experiences exist along a continuum • Don’t panic! • If therapist is emotionally overwhelmed, client can easily become so as well • Even when you have no idea how to respond to a particular statement, you still have shared experiences and goals – remember them!
The Meat of a Course of CBT • Assessment • Formulation • Discovery and change
CBT Assessment • Examine presenting problems in terms of: • Thoughts and beliefs • Emotion and mood states • Behavioral patterns and goals
CBT Formulation • Utilize the patient’s presenting problems and goals to develop a set of prioritized intervention strategies. • Alliance depends on a shared problem/goal • Re: normalize, don’t panic, focus on outcomes • Client should be explicitly shown the therapist’s thought process (also: homework) • Re: most beliefs and behaviors change slowly • Re: you can model an evidence-based approach to solving everyday problems
The CBT Loop:a model for discovery and change Thoughts Emotions Behaviors
The CBT Loop and Psychosis • In Psychosis, the following approaches are frequently useful: • Generating alternative explanations (thought focus) • Identifying and modifying attentional biases (sensation and emotion focus) • Identifying and modifying safety behaviors (behavioral focus)
The CBT Loop and Psychosis • In Psychosis: • Generate and evaluate alternativeexplanations (these need to be in part client-generated, especially for intrusive thoughts) • Counter evidence? • What if it were someone else with the same belief? • How might someone else explain it? • Has experience ever proved me wrong before? • Is reality shades of grey, instead of black-and-white?
The CBT Loop and Psychosis • In Psychosis: • Work to identify and modify attentional biases • Too much focus on internal experience? • Too much focus on one particular stimulus? • What am I missing? • Work to identify and modify safety behaviors • How do you respond? • What does this response lead to? • How might others respond? • What would happen if you did it differently?
CBT in practice Case examples for discussion
Case #1 • M has stopped playing soccer regularly, because when he runs he notices that “my right quadriceps muscle isn’t attached correctly to my right knee and I can feel this flaw whenever I land a hard stride; therefore, my right leg is misshapen” (physical therapy exam and MRI were both negative)
Case #1 …what might be some: • Thoughts and Alternative Explanations? • Emotions/Sensations and Attentional Biases? • Behaviors and Safety Behaviors?
Case #2 • C notes that she can not trust her psychiatrist, because the heater in his office has the phrase “Trap #24” written on it, which suggests that he is part of a conspiracy to hospitalize her against her will.
Case #2 …what might be some: • Thoughts and Alternative Explanations? • Emotions/Sensations and Attentional Biases? • Behaviors and Safety Behaviors?
Psychosis is not: • One thing • One type of reaction • One type of process • Something “other than” neurosis
What brains share • We are constantly and unconsciously processing information • What if this process went awry? • What would the subjective experience be like?
Distinguishing Novelty • We are novelty seeking organisms • We preferentially attend to novel stimuli • This process is very fast and initially unconscious
Ignoring Redundancy • We are faced with multiple stimuli at any given time • Most of these stimuli are irrelevant to our current state • We filter out redundant information unconsciously
Experiment 1 • Listen • Listen • Listen • Listen • Listen • Listen • Listen
Experiment 1 • Listen • Watch • Learn • Distill • Interpret • Integrate • Repackage
Distinguishing Self from Other • We have a clear boundary • We are constantly processing information both internal and external to that boundary • We therefore “tag” self-generated stimuli
In a sense then… • CBT is a perfect model for psychosis • Hallucinations = lower order errors in information processing (“bottom up”) • Distorted thoughts = higher order errors in information processing (“top down”)
