Cognitive Behavioral Therapy for Psychosis (CBTp)

Structure of CBT Session

• Agenda Setting - 2 Mins
• Homework Review - 5-10 Mins
• Clinician Item and Homework setting - 15 mins
• Client Item - 15 Mins
• Feedback - 2 Mins

Catch it, Check it, Change it

Problem

• Trigger(Makes the problem more likely to happen - eg. having an argument with my partner) & Modifier(Makes the problem better or worse - eg. Sleep, mood)
• Precipiter(Something that happened - significant life event)
• Beliefs
  • Vulnerability Factors(Genetics, childhood trauma)
• Maintenance
  • Treatment Targets

Common Maintenance Processes

Things that keep a Psychosis going on

• Safety Behaviors and Avoidance - if something is frightening, we avoid it
• Reduction of Activity - stay in all day when depressed
• Catastrophic Misinterpretations -
• Self fulfilling prophecies
• Performance Anxiety
• Fear of Fear
• Perfectionism
• Short-Term Rewards - substance use, self harm

Different mental health issues as viewed by CBT

• Psychosis: traditionally discussed as the difficulty in distinguishing what is real from what is not real.

• Delusion: fixed false beliefs held in the face of contrary evidence

• Depression -> distorted beliefs about self worth & Efficacy

• Anorexia -> fixed false belief about being overweight

• Panic Disorder -> Distorted belief about physical safety

• OCD -> Distorted beliefs - thought-action fusion

Psychosis is characterized by culturally unacceptable interpretation of experiences

• Stigmatizing and distressing => Maintains Psychosis

Implications:

• Normalizing may reduce stigma and distress
• CBT techniques might be successful in psychosis too.

Eg. 2 woman feel a lump in their breast, one gets test that says its benign - but still believe that its cancer. Other thinks that its a govt. installed thought monitoring device. Second woman is said to have psychosis.

Self-Regulatory Executive Functioning Model

CBT Theory of Auditory Hallucinations(AHs)

AHs are mis-attributed internal events(Eg. verbal thoughts, inner speech)

Individuals with psychosis are...

• Less likely to recognize thoughts as their own
• Less likely to recognize own voice played back with minor distortions
• Tend to assuming that ambiguously sourced info was generated externally

Goal might not be to remove distorted belief entirely - reduction of conviction can be very helpful

Types of Homework

• Information Collection
  • Current Functioning
  • Current Symptoms, experiences, thoughts, affactive states, etc.
  • Track substance use and relationship to symptoms
• Experiments
  • Discover what happens when client thinks/behaves differently
  • Exploration of different outcomes from different actions
• Practice New Skills
  • Intense Repetition is necessary for behavior change

What to choose for homework: 3 R's

• Is it Relevant
  • To the model
  • To the case conceptualization
  • To the content of the session
  • To the clients goals
• Is it Realistic
  • Is it achievable
  • Is it challenging enough to feel significant but not so difficult that its impossible
• Is it the clients Responsibility
  • Is it within the client's control
  • Is it the clients responsibility to address

Homework should be chosen by both therapist and the client

• Ensure client understands the rational
• If client does not do the homework...
  • Do not shrug and move on - find out why
  • Be curious, not confrontational
  • Involve support network/family