Cognitive Behavioral Treatment for Persons with Psychosis: A New Direction in Psychological Intervention

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1 Isr J Psychiatry Relat Sci Vol 46 No. 4 (2009) Cognitive Behavioral Treatment for Persons with Psychosis: A New Direction in Psychological Intervention Sara Freedman, PhD,¹ Ilanit Hasson-Ohayon, PhD,² and David Roe, PhD³ ¹ Department of Psychiatry, Hadassah University Hospital, Jerusalem, Israel ² Department of Psychology, Bar-Ilan University, Ramat Gan, Israel ³ Department of Community Mental Health, University of Haifa, Haifa, Israel Abstract: Psychotic symptoms appear frequently in schizophrenia and other related disorders, and until relatively recently were not generally considered to be amenable to psychological interventions. Recent studies have changed these conceptualizations. Theoretical models, based on a stress vulnerability perspective, show how misinterpretations of anomalous experiences are factors in both the development and maintenance of psychosis. This review describes CBT treatment for persons with psychosis which focuses on education about symptoms and the cognitive model as well as a collaborative exploration of thoughts and schemas surrounding delusions and hallucinations. Treatment outcome studies show that CBT is an effective and acceptable treatment for psychosis. Introduction Delusions and hallucinations are the most common symptoms that occur in psychosis-related disorders, such as schizophrenia and schizoaffective disorder. These disorders include a diagnosable mental, behavioral or emotional disorder that meets the criteria of the DSM-IV-R and results in significant functional impairment. This paper will describe a cognitive behavioral model for the treatment for people suffering from these symptoms with special attention to schizophrenia as a typical example of a psychotic disorder. Historically, the long-term prognosis for schizophrenia and related disorders was thought to be poor, with a steady deterioration over the lifespan. Beginning with the International Pilot Study of Schizophrenia carried out by the World Health Organization in 1969 (1), there have been a series of rigorous longitudinal studies conducted around the world which have demonstrated a broad heterogeneity in outcome for schizophrenia and related disorders (2, 3). Heterogeneity was found in the course and outcome of illnesses across people, as well as across various domains of functioning within any given individual and over time. The findings from these long-term outcome studies generated a more optimistic outlook with regard to the course and outcome of people with schizophrenia and related disorders. The growing optimism has been manifest through the gradual shift toward emphasizing recovery as a desirable goal for mental health services (4). While, to date, most of the effort to promote recovery for persons with psychosis has been through legislation, policy and rehabilitations services, Cognitive Behavioral Therapy (CBT) is increasingly being recognized as an effective intervention. CBT is a structured psychological intervention that attempts to assist persons improve their adaptive and emotional functioning, primarily by identifying and replacing inaccurate beliefs or maladaptive cognitions that cause or maintain dysfunction (5). Originally created to address depression, its use has steadily expanded to address a wide variety of disorders including personality disturbances (6) and substance dependence (7, 8). Address for Correspondence: Sara Freedman, PhD, Department of Psychiatry, Hadassah Hebrew University Hospital, Jerusalem 91120, Israel. sarafreedman@gmail.com IJP 4 English 16 draft 11 balanced.indd 298 2/23/2010 1:55:51 PM

2 sara freedman et al. 299 Most recently, it has been applied successfully to treating people with psychosis. This paper will describe the CBT approach to treatment for people with psychosis. Much of this work has concentrated on people suffering from schizophrenia; some studies have also included psychosis related to other disorders. The cognitive behavioral model of psychosis and treatment strategies will be examined, and the results of randomized controlled trials will be described. CBT for psychosis was developed to address the positive symptoms of psychosis, although some studies have reported effects on other factors, such as negative symptoms and functioning. The emphasis of this paper is on the positive symptoms of psychosis; the results regarding other factors are also reported. Cognitive Behavioral Models of Psychosis As with other disorders, CBT for psychosis is rooted in theoretical models (e.g., 9, 10). These models attempt to explain the development and maintenance of symptoms, as well as provide the rationale for the therapeutic interventions. A composite case will be described to help illustrate the theoretical model and the therapy. W., a 29-year-old male, came to therapy following his first psychotic episode. He described a difficult relationship with his parents. At the age of 17 W. had been the victim of a knife attack. Shortly afterwards, he described hearing voices, where people would say we are out to get you. W. stayed at home and refused social contact because of these voices. W. believed that there was a conspiracy in his town, with many people (including his family) involved in an attempt to kill him. The CBT model views psychosis as an illness, rather than a disease, which has psychological as well as biological explanations, and thus psychotic symptoms are understood in psychological terms. The model draws on several bodies of research: the current overview will provide a brief basis for understanding the model. Firstly, all CBT models are predicated on the idea that the way in which we think influences our feelings, behavior and physiological responses, and vice versa. Moreover, the large amount of information that is processed in the brain is organized into higher and lower level structures. The former, known as schemas, or basic assumptions, relate to all types of experiences, including relationships and perceptions of self and others. These schemas are activated by cues and certain situations. Once activated, they provide the lens through which the world is perceived, and can lead to ongoing interpretations of the world (i.e., automatic thoughts). For instance, a person may have been brought up in a judgemental environment, and developed the schema that everyone is against me. This schema may be activated mainly when she is being criticized, and may lead to negative automatic thoughts such as people are out to get me or I am worthless. Secondly, thinking patterns generally display distortions. In most individuals, these distortions are positive ones, so that information processing results in selectively remembering and focusing on good things, which leads to incorrect and overly optimistic beliefs such as it will never happen to me (11). When these distortions are negative, they are associated with different psychopathologies, for instance focusing on the negative is related to depression, and focusing on danger is related to PTSD. Thirdly, the CBT model assumes that symptoms experienced by people with psychosis, such as hallucination and delusions, can be conceptualized as existing along a continuum with such experiences found in the general population (12). This contention is well supported by research: studies among the general population have found that up to onequarter of individuals experience voices describing their behavior or hearing voices talking about them in the third person, and 17% of students experienced hearing their thoughts spoken out loud (13, 14). Hallucinations are also found in other psychiatric disorders, such as PTSD, as well as occurring in situations of sensory and food deprivation (15), and bereavement (16). The experience of hallucinations may also have a cultural aspect (14). Around a quarter of respondents from the general population indicate that they have delusional thinking (17). There is a large body of research pertaining to distortions commonly found in everyday thinking (18). Thus, as with hallucinations, delusions are not found only in those suffering from IJP 4 English 16 draft 11 balanced.indd 299 2/23/2010 1:55:51 PM

3 300 Cognitive Behavioral Treatment for Persons with Psychosis psychotic disorders, and can thus be hard to differentiate from normally strongly held illogical beliefs. The fourth area of research relevant to this model comes from cognitive neuropsychology. Numerous studies have shown that individuals who are vulnerable to hallucinations have a lower threshold for perceptual imagery, such that the likelihood of hearing something that is not actually there is higher in these individuals (19). Once these auditory images are perceived, then these individuals are also less likely to perform some type of reality check. Additionally, individuals with a propensity to hallucinations are more likely to attribute these phenomena to an external source. It has been proposed (19) that cognitions, generally those that provoke a high level of distress, known as hot cognitions, are often the content of hallucinations, and cross from thought to hallucination due to the lower threshold for perceptual imagery. The content of these hot cognitions, and therefore hallucinations, is similar to that found in other disorders: you are worthless (depression), there is dirt everywhere (OCD), you are in danger (PTSD). In these individuals, they are experienced as real rather than as internal thoughts, images or memories. In a similar manner, cognitions and schema can become delusions. People with a vulnerability to psychosis are more likely to use two distorted schemas: self-focus and externalizing. Thus, a person who hears a strange sound will a) assume that it is directed at him, and b) assume that it is not internally generated. He is therefore more likely to come to the conclusion that the sound is something threatening coming from the people near him, and directed at him, and he is being attacked. W. may hear the noise of the air conditioning, and assume that is the noise of the spy equipment installed by his enemies. As with hallucinations, the lack of reality checking will increase the likelihood of these misperceptions taking place. Certain factors also maintain these symptoms. Interacting with the voices or listening to them is likely to increase their saliency. Beliefs about hallucinations also affect their occurrence. Believing that a voice is dangerous, for example, will lead to more attention being paid to it, which will increase it occurring again. Psychotic symptoms are likely to happen as a result of an interaction of these four factors (the relationship between thoughts, feelings and behavior; distortions in thinking; the frequent occurrence of anomalous experiences; and neurocognitive changes found in people with psychosis) and particularly following periods of stress, such as life changes, or traumatic events (20). How might this happen? In W. s case, due to an underlying biological vulnerability, he is more likely to have perceptual experiences. Following a period of stress, when he has been experiencing more of these odd and disturbing symptoms, he attempts to understand what is happening to him. He has a schema that people do not like him, and thus he interprets both his strange symptoms and other people s reactions through the lens of this belief. Having hallucinations is understood as a punishment from the people out to get him, when hearing people talk he immediately assumes that they are talking about him, and so on. W. s behavior then maintains these experiences: listening for the voices and avoiding social contact. This model facilitates the collaborative relationship needed in CBT, since it takes the perspective of the patient, assuming that any person who had cognitive-neuropsychological deficits would have very bizarre experiences, and would probably come to develop strange theories to account for such experiences (21). Therapy CBT for all disorders has in common certain elements, for instance therapy is relatively short-term, and is based on a collaborative relationship. CBT for psychosis requires certain modifications that illustrate the challenges of working with this population. For example, when W. came to therapy, he was not interested in talking to the therapist as he believed that the therapist was part of the conspiracy against him. By taking the patient s perspective on this situation, the therapist was able to address his discomfort by acknowledging it, and providing clear indications regarding who she was, and what her role was. The first step in CBT is assessment and formulation (22, 23). In the assessment, psychological (i.e., IJP 4 English 16 draft 11 balanced.indd 300

4 sara freedman et al. 301 risk of depression), psychosocial (i.e., social relationships), and social factors (i.e., unemployment) should be addressed in addition to the examination of symptoms (24). Symptoms can be assessed by general symptom measures such as the PANSS (25) and the BPRS (26), or by instruments designed to track treatment changes in symptom dimension over time such as the Psychotic Symptom Rating Scale PSYRATS (24). In addition to these instruments other illness-related measures are used to track changes such as medication compliance and re-hospitalizations. The formulation includes the integration of factors, internal antecedents and environmental influences, which contribute to psychotic symptoms, and act as a working explanation in the therapy (24). For example, in the case of W, experiencing the auditory hallucination we are out to get you was understood in the context of a trigger (social meeting). The voice was appraised by W. as real, and resulted in changes in affect (being scared), cognitions (preoccupation with self schema), behavior (looking out for potential attackers), and physiology (being tense). These consequences in turn increased the occurrence of the voices resulting in a vicious circle. The delusion they want to kill me was formulated in a similar manner. As therapy progressed these formulations were edited and changed according to additional information that was obtained. For example, in the fifth session W. shared with the therapist that every time he met his neighbor he crosses the street to avoid him. This was understood as safety behavior and added to the formulation. Rapport building and psychoeducation are the next stage in treatment. Consistent with the model presented above, therapists teach patients about the stress vulnerability model and also about the relation between cognitions, affect and behavior, and how this pertains to their situation. With W, the impact of traumatic events such as a knifing were discussed in detail, and their effect on W. s symptoms was examined. For the first time, W. was given both a name and explanation for the difficulties he was having. W. also started to understand how his cognitions ( they want to kill me ) affect his feelings (anxiety) and behavior (being alert and avoiding people). The choice of techniques that are used in CBT interventions for persons with psychosis should be according to the specific formulation (27). With W, his hallucinations and delusions were treated with techniques aimed to improve reality testing. These included evaluating/assessing the evidence that confirmed or disconfirmed each specific hallucination or delusion, considering alternative explanations and rating them according to the degree to which the belief was firm. While doing this, W. considered attributing the occurrence of the voices to stress and less to a real external voice. He could understand that the voices were not necessarily real. His paranoid delusions were challenged using Socratic questioning. W. was asked for evidence both supporting, and against, his beliefs. When challenging the delusion my mother is going to kill me, he said that the knife she bought yesterday might be for kitchen use and not for killing him. In addition, as a second stage, the use of behavioral experiments, testing out in practice the delusions, was also used to test reality. W. was given assignments to test his delusions. After challenging the delusions, he exposed himself to situations in which they could be tested. For example, he came to the kitchen when his mother was there cutting vegetables. This behavioral experiment, resulting in his mother not killing him, helped decrease the strength of W. s delusions. The issue of safety behavior was also discussed with W, as staying at home and avoiding social contact was preventing W from encountering information that might modify his delusions. In regard to the negative symptoms that W. was experiencing, such as social withdrawal, lack of self-care and anhedonia, cognitive behavioral techniques often used with depression were utilized (27). W. was asked to monitor his activities, and pleasurable and functional activities were gradually added to his daily life. This was monitored on graphs, so that W. could see progress, and rewards were also given for behavioral change. Relapse prevention is an integral part of therapy. It involves schema-focused intervention which aims to address dysfunctional schemas as vulnerability factors; developing a blueprint (a written summary) of what was learned in therapy; and prodromal monitoring which aims to identify IJP 4 English 16 draft 11 balanced.indd 301

5 302 Cognitive Behavioral Treatment for Persons with Psychosis warning signs prior to relapse and ways to cope with them (23). W. s schemas regarding himself, such as, I am bad, were challenged, since it can activate delusions such as they will kill me. In addition, W. wrote, with the help of the therapist, a written summary of his formulation and therapy progress. Early warning signs, such as not sleeping, were identified, as well as ways to cope with them, such as making an appointment with a psychiatrist. Effectiveness of CBT for Psychosis: Research Studies More than 30 randomized controlled trials examining the effectiveness of CBT for psychosis have now been published, encompassing nearly 2,000 patients (28). These trials have included both individual and group CBT, involved both expert and novice therapists, and utilized a variety of CBT techniques. Most studies have targeted positive symptoms, although many also report effects on negative symptoms (e.g., 29, 30). The results of the most recent meta-analysis indicate that CBT has a modest effect on positive symptoms, as well as on negative symptoms, functioning and mood. A recent study (31) targeted patients who had recently relapsed, and examined the effectiveness of CBT versus family intervention at preventing further relapse. The results indicate that neither treatment was effective, and the authors conclude that while CBT is helpful for patients in a stable phase of illness with ongoing distressing positive symptoms, CBT that focuses on relapse is not helpful in recently relapsed patients. A previous meta-analysis concluded that CBT was more effective for acute episodes than chronic ones (32), although a recent study (33) showed that while cognitive therapy with acute psychosis accelerates recovery in initial stages, it was not more effective than befriending by one-year follow-up. Conclusions CBT for psychosis is an effective intervention for psychosis, and there now exists a large body of evidence to support its use with this population. CBT for psychosis is as complex as its target population. As such, any work with people suffering from psychosis will need to be adaptable and creative. Treatment manuals are based on a personal case formulation approach, and stress the need for flexibility and special work on engagement (23, 34). In addition, when working with people with psychosis, attention should be given to issues of stigma and insight since they may affect the patient willingness to accept the medical model at the stage of psychoeducation. Identifying cognitions regarding the illness, such as no one wants to be a friend of someone with mental illness, is important in examining and challenging the personal meaning a patient may have about his illness. 38. References 1. Strauss J S, Carpenter W T, Jr. The prediction of outcome in schizophrenia. II. Relationships between predictor and outcome variables. A report from the WHO international pilot study of schizophrenia. Arch Gen Psychiatry 1974; 31: Harding CM, Zubin J, Strauss JS. Chronicity in schizophrenia: Fact, partial fact, or artifact? Hosp Comm Psychiatry 1987; 38: Hopper K, Harrison G, Janca A, Sartorius N. Recovery from schizophrenia An international perspective. Oxford: Oxford University, Department of Health and Human Services. Achieving the promise: Transforming mental health care in America. President s New Freedom Commission on Mental Health. Final Report. Rockville, Maryland: Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services, Beck A T, Rush A J, Shaw B F, Emery G. Cognitive therapy of depression. New York: Guilford, Beck A T, Freeman A. Cognitive therapy of personality disorders. New York: Guilford, Marlatt A, Gordon J. Relapse prevention. New York: Guilford, Monti P, Abrams D, Kadden R, Cooney N. Treating alcohol dependence: A coping skills training guide. New York: Guilford, Beck AT, Rector NA. Cognitive approaches to schizophrenia: theory and therapy. Annu Rev Clin Psychol 2005; 1: Garety P A, Kuipers E, Fowler D, Freeman D, Bebbington PE. A cognitive model of the positive symptoms of psychosis. Psychol Med 2001; 31: Weinstein ND. Why it won t happen to me: Perceptions of risk factors and susceptibility. Health Psychol 1984; 3: IJP 4 English 16 draft 11 balanced.indd 302

6 sara freedman et al Strauss JS. Hallucinations and delusions as points on continua function: Rating scale evidence. Arch Gen Psychiatry 1969; 21: Slade P D, Bentall RP. Sensory deception: A scientific analysis of hallucination The Johns Hopkins series in contemporary medicine and public health. Baltimore, Md.: Johns Hopkins University, Johns LC, Nazroo JY, Bebbington P, Kuipers E. Occurrence of hallucinatory experiences in a community sample and ethnic variations. Br J Psychiatry 2002; 180: Siegel RK. Hostage hallucinations: Visual imagery induced by isolation and life-threatening stress. J Nerv Ment Dis 1984; 172: Grimby A. Hallucinations following the loss of a spouse: Common and normal events among the elderly. J Clin Geropsychol 1998; l4: Peters E, Joseph S, Day S, Garety P. Measuring delusional ideation: The 21-item Peters et al. Delusions Inventory (PDI). Schizophr Bull 2004; 30: Tversky A, Kahneman D. Judgment under uncertainty: Heuristics and biases. Science 1974; 185: Beck AT, Rector NA. A cognitive model of hallucinations. Cogn Ther Res 2003; 27: Nuechterlein KH, Dawson ME. A heuristic vulnerability/ stress model of schizophrenic episodes. Schizophr Bull 1984; 10: Fowler D, Garety P, Kuipers E. Cognitive behaviour therapy for psychosis: Theory and practice (Wiley Series in Clinical Psychology). Chichester: John Wiley & Sons Ltd., 1995: p Haddock G, Tarrier N. Assessment and formulation in the cognitive behavioral treatment of psychosis. In: Tarrier N, Wells A, Haddock G, editors. Treating complex cases the cognitive behavioral therapy approach. Chichester: John Wiley, 1998: pp Morrison A P. Cognitive behavioral therapy for psychotic symptoms in schizophrenia. In: Tarrier N, Wells A, Haddock G, editors. Treating complex cases the cognitive behavioral therapy approach. Chichester: John Wiley, 1998: pp Haddock G, McCarron J, Tarrier N, Faragher EB. Scales to measure dimensions of hallucinations and delusions: The psychotic symptom rating scales (PSYRATS). Psychol Med 1999; 29: Kay S R, Opler LA, Lindenmayer JP. The positive and negative syndrome scale (PANSS): Rationale and standartization. Br J Psychiatry 1989; 155: Overall J, Gorham D. The brief psychiatric rating scale. Psychol Rep 1962; 10: Rector N, Beck AY. Cognitive therapy for schizophrenia: From conceptualization to intervention. Can J Psychiatry 2002; 47: Wykes T, Steel C, Everitt B, Tarrier N. Cognitive behavior therapy for schizophrenia: Effect sizes, clinical models, and methodological rigor. Schizophr Bull 2008; 34: Hall PL, Tarrier N. Short term durability of a cognitive behavioural intervention in psychosis: Effects from a pilot study. Behav Cogn Psychother 2004; 32: Rector NA, Seeman MV, Segal ZV. Cognitive therapy for schizophrenia: A preliminary randomized controlled trial. Schizophr Res 2003; 63: Garety P A, Fowler DG, Freeman D, Bebbington P, Dunn G, Kuipers E. Cognitive-behavioural therapy and family intervention for relapse prevention and symptom reduction in psychosis: Randomised controlled trial. Br J Psychiatry 2008;192: Zimmermann G, Favrod J, Trieu VH, Pomini V. The effect of cognitive behavioral treatment on the positive symptoms of schizophrenia spectrum disorders: A metaanalysis. Schizophr Res 2005; 77: Jackson H J, McGorry PD, Killackey E, Bendall S, Allott K, Dudgeon P, Gleeson J, Johnson T, Harrigan S. Acute phase and 1-year follow-up results of a randomized controlled trial of CBT versus befriending for first-episode psychosis: The ACE project. Psychol Med 2008; 38: Kingdon D. Cognitive behavioral therapy of psychosis: Complexities in engagement and therapy. In: Tarrier N, Wells A Haddock G, editors. Treating complex cases the cognitive behavioral therapy approach. Chichester: John Wiley, 1998: pp IJP 4 English 16 draft 11 balanced.indd 303