CBT for Psychosis

A Symptom-based Approach

Roger Hagen, Douglas Turkington, Torkil Berge, Rolf W. Gråwe, Roger Hagen, Douglas Turkington, Torkil Berge, Rolf W. Gråwe

• Publisher: Routledge
• Year: 2013
• eBook ISBN: 9781136837975
• Edition: 1
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

This book offers a new approach to understanding and treating psychotic symptoms using Cognitive Behavioural Therapy (CBT). CBT for Psychosis shows how this approach clears the way for a shift away from a biological understanding and towards a psychological understanding of psychosis.

Stressing the important connection between mental illness and mental health, further topics of discussion include:

• the assessment and formulation of psychotic symptoms
• how to treat psychotic symptoms using CBT
• CBT for specific and co-morbid conditions
• CBT of bipolar disorders.

This book brings together international experts from different aspects of this fast developing field and will be of great interest to all mental health professionals working with people suffering from psychotic symptoms.

Part I

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Cognitive models of psychosis and their assessment

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Chapter 1

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Introduction

CBT for psychosis: A symptom-based approach

Roger Hagen and Douglas Turkington

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This chapter will start with a brief outline of cognitive behavioural therapy (CBT). This outline will be followed by an introduction to the use of CBT for psychotic problems. The final part of the chapter serves as an introduction to the rest of the book and how the book is organized.

What is cognitive behavioural therapy?

Cognitive behavioural therapy emphasizes the importance of the role of cognitions and behaviour in the formation and maintenance of psychiatric disorders and emotional problems. Even if there could be said to be various alternative versions of delivering cognitive behavioural therapies, there are some common factors related to treatment principles and cognitive behavioural techniques which integrate these different approaches. We will shortly try to describe some of these common treatment principles and cognitive behavioural techniques, but for a further in-depth description for those who are not familiar with CBT, see Beck (1995) or Wright et al. (2006) which serve as excellent introductory textbooks to cognitive behavioural therapy.

CBT interventions are designed to treat specific disorders or problems. The patient and the therapist try to set explicit goals to overcome these specific problems in the beginning of therapy, and the cognitive and behavioural interventions are tailored to treat these problems based on the patient’s problem list. The patient’s difficulties and goals for therapy are then operationalized in what is called a cognitive case formulation, which could be described as a hypothesis about the nature of psychological difficulties underlying the patient’s symptoms. The cognitive case formulation is derived theoretically from existing models of human learning and cognition. The cognitive behavioural therapies emphasize a collaborative relationship between the patient and the therapist, and require that both the patient and the therapist take an active role in the treatment process and progress.

Based on the notion that cognitions and behaviour play an important role in both the formation and the maintenance of most psychiatric disorders, cognitive behavioural interventions seek to reduce distress and enhance adaptive coping by changing maladaptive beliefs and providing new skills (Grant et al., 2005). The various approaches differ somewhat in the extent that they emphasize cognitive mechanisms or more behavioural ones (Hollon and Beck, 2004). The goal of cognitive behavioural interventions is to change maladaptive beliefs and behaviours using a wide range of techniques. These techniques include elements of self-monitoring; identifying and challenging negative thoughts and assumptions that maintain problematic behaviour and experiences; de-catastrophization; scheduling activities; and behavioural experiments that in turn aid further self-monitoring and challenge dysfunctional beliefs (Wright et al., 2006). CBT appears to be effective for a broad range of clinical and medical disorders. Moreover, there are numerous indications that cognitive and cognitive behavioural interventions may produce more lasting changes than other psychotherapeutic interventions to both Axis I and Axis II disorders (Butler et al., 2006).

What is CBT for psychosis?

Historically, we distinguish between three paradigms in our understanding of psychosis (Morrison et al., 2004). The illness paradigm was introduced by Kraepelin (1899/1990) at the beginning of the twentieth century. A clear distinction was drawn between normality and abnormality, and the causes of a certain number of diagnosable mental illnesses were understood as inherited brain disorders or infections, e.g. syphilitic mental disorders. The second paradigm is called the stress vulnerability model, where biologically and psychologically predisposed individuals may become psychotic if they are exposed to stressing life experiences (Zubin and Spring, 1977). The various disorders, for example schizophrenia, are thought to lie along a continuum with normal behaviour and experiences, and there is a possibility that one can make therapeutic change by influencing the environment and strengthening the person’s ability to cope with the psychotic disorder. The third paradigm is the symptom-focused paradigm (Bentall, 2003). Here each single symptom is emphasized, for example voice hearing, delusions/ unusual assumptions, thought disorder or negative symptoms, rather than using broad diagnostic categories. One is concerned with the possibility of coping with and understanding the symptoms and the ability to be able to function socially and professionally, more than curing the disorder as such. Cognitive behavioural therapy for psychosis has come to recognize the importance of focusing on each single symptom, as this seems to create a foundation for better results for treatment. Psychotic experiences are, from a cognitive behavioural view, seen as experiences and not just as symptoms of an underlying disorder. The exploration of the individual’s experiences and beliefs related to their symptoms is therefore essential.

Bentall (2003) further suggested that there is a need for a radically new way of thinking about psychotic symptoms, mostly related to the fact that the boundary that has been set between bipolar disorders and schizophrenia has been disputed in relation to new research in this field. Psychotic symptoms such as mania, delusions and voice-hearing are actually difficult to sort into neat categories as diagnoses, and are best understood on a continuum of symptoms. Kingdon et al (2008) have taken this approach further and suggest that there might be five distinct subgroups of schizophrenia based on symptoms and causation. These are: sensitivity disorder (high vulnerability, negative symptoms and cognitive deficits); traumatic psychosis (trauma contributing to causation, critical hallucinations and depression); drug-induced psychosis (hallucinogen use, paranoid delusions and negative symptoms); anxiety psychosis (schema vulnerability and systematized delusions); and catatonia. In line with this approach CBT plays an important role in both the understanding and the treatment of symptoms.

Since the first description of cognitive therapy for paranoid delusions (Beck, 1952), the empirical support for using CBT to treat psychotic symptoms has been widely established (Dickerson, 2004; Gaudiano, 2005; Gould et al, 2001; Rathod and Turkington, 2005; Rector and Beck, 2001; Turkington et al, 2006; Tarrier and Wykes, 2004). For many decades the dominant view was that psychosis was considered a biological condition insusceptible to psychological interventions; however, more recent research has shown that positive symptoms are on a continuum with normality and therefore may be treatable with the same CBT techniques used to treat anxiety and depression (Bentall, 2007; Kuipers et al, 2006). The cognitive model of psychosis conceptualizes a combination of factors that shape and maintain positive symptoms such as delusions and auditory hallucinations (Garety et al, 2001), where reasoning and attributional biases may play a particular role in symptom formation and the maintenance of these symptoms (Bentall, 2003; Freeman and Garety, 2004).

In this introduction we will try to sketch out a brief synopsis of the most essential therapeutic processes and interventions in CBT for psychosis. To therapists who are not familiar with this approach to treating psychotic symptoms, we recommend Kingdon and Turkington (2005) and Wright et al. (2008), which will serve as introductory books for novices carrying out CBT for psychosis. Some of the chapters in Part II of this book could also serve as good examples explaining the essential aspects of CBT for psychosis.

The primary goals in CBT for psychosis are to teach the patient to identify and monitor their thoughts and assumptions in specific situations, and to evaluate and correct these thoughts and assumptions against objective external evidence and actual circumstances. Delusional beliefs and auditory hallucinations are based upon thoughts and assumptions that the patient believes to be true and real, and they are held with great intensity and often preoccupy the person. These beliefs cause distortions in the processing of new information, which also maintain the patient’s delusional beliefs and auditory hallucinations (Hagen and Nordahl, 2008).

The CBT of psychosis can be divided into different phases related to therapeutic processes taking place between the patient and the therapist. In the beginning of therapy, the focus is set on engaging the patient in therapy and trying to create a therapeutic alliance. Non-specific therapeutic factors such as empathy and warmth are of great importance in the process of building a collaborative relationship between patient and therapist. A style of active listening, trying to have a common language for the patient’s symptoms, having an openness to their experiences and avoiding using a confrontational style are all factors which could enhance engagement in therapy (Chadwick, 2006; Kingdon and Turkington, 2005).

The next phase is related to the process of education and normalization of the patient’s psychotic symptoms. The aim of this is to promote an understanding of other psychological phenomena that resemble symptoms of psychosis. Research shows that normalizing is a main factor predicting a good clinical outcome when it is linked to other formulation techniques, such as tracing the antecedents of breakdown, de-catastrophizing psychosis and education about the psychotic illness (Dudley et al., 2007). Normalization is closely related to the assumption already described in this chapter that psychotic experiences are continuous with ordinary human experiences, and that normalization could be used as a therapeutic tool towards forming a strong therapeutic alliance. Integrated in the normalization process is also psychoeducation. This seems crucial for people suffering from psychotic disorders because of the myths surrounding these illnesses. Psychoeducation and information about the illness must be adapted to the individual psychotic symptoms. Given in an appropriate manner, this can help people feel listened to and understood. Education that normalizes is highly valued (Kingdon and Turkington, 2005).

Embedded in the process described above are assessment and information gathering, related to the process of developing and sharing a case formulation with the patient. The ultimate goal of the therapist is for both parties to try to understand the patient’s psychotic symptoms. The two most important areas to identify when working from a cognitive behavioural viewpoint with psychotic patients are how the psychotic symptoms appear, and what sense the patient makes of them. Case formulation develops out of the assessment process, and will sometimes guide it, and provides a framework for developing therapeutic interventions (Kingdon and Turkington, 2005), which is the next phase when carrying out CBT for psychosis.

Based on the formulation, a treatment plan is made in which the patient and the therapist are working with the individual’s beliefs and thoughts related to their understanding of their symptoms, and trying to build new alternative explanations and coping strategies. The aim is not to make the psychotic symptoms go away, but to restructure old appraisals of voices and delusions, and to generate new alternatives which are not as distressing as the original ones. Instead of just focusing on a decline in symptoms, the treatment should be seen as effective if there is a decline in emotional distress in the patient as a result of therapy (Birchwood and Trower, 2006) and an improved social outcome (Turkington et al., 2007). The use of cognitive and behavioural techniques is implemented in a non-confrontational and collaborative manner in this working phase.

The closing phase of CBT for psychosis is the process of relapse prevention and recovery. Feelings of fear, depression, helplessness, hopelessness, embarrassment and shame seem to be common factors prior to relapse in psychosis (Gumley and Schwannauer, 2006). Relapse prevention is an essential aspect in CBT for psychosis, and it is of great importance that psychotic relapse is avoided, related to the personal costs and suffering to the patient. Avoiding relapses is important, but must not overshadow the road to emotional recovery and an improvement in quality of life. Research related to recovery from psychosis suggests that there are both personal and environmental factors which both therapist and patient could build on to make a recovery fully possible (Wilken, 2007). Generating hope and belief that recovery is possible and giving the patient a high quality of professional services are criteria which we can say are already implemented in cognitive behavioural therapy for psychosis.

The content of this book

The content of this book follows a logical progression in learning about CBT for psychosis, and is divided into four parts, each focusing on different aspects. Part I focuses on the cognitive models of psychotic symptoms and their assessment. Chapter 2 (Kinderman) presents an update on the cognitive models of auditory hallucinations and the general consensus in the CBT field that auditory hallucinations arise from misattributed cognitions, but less consensus from research as to the specific nature of these cognitions. This chapter reviews these different theories and also gives examples on how auditory hallucinations can best be understood from within a cognitive behavioural framework. Chapter 3 (Turkington et al.) explores the cognitive models pertinent to delusion formation and maintenance. Case vignettes are used to illustrate the key CBT techniques pertinent to engaging, formulation and the reality testing of delusions. The pertinence of schemas to delusional content is described. Chapter 4 (Peters) is about assessment in psychosis. As already described, in recent years there has been a growing and fruitful debate on the merits of using ...

Table of contents

• Cover Page
• Half-Title Page
• Series Page
• Title Page
• Copyright Page
• Table of Contents
• Figures and tables
• List of contributors
• Acknowledgements
• Preface
• PART I Cognitive models of psychosis and their assessment
• PART II The practice of CBT for persons with psychotic symptoms
• PART III CBT and co-occurring problems
• PART IV CBT and bipolar disorders
• Name index
• Subject index