CBT for Schizophrenia

Evidence-Based Interventions and Future Directions

Craig Steel, Craig Steel

• Publisher: Wiley-Blackwell
• Year: 2012
• ISBN:
  9781118321355
• Edition: 1
• Topic: Psychology
• Subtopic: Cognitive Behavioral Therapy (CBT)
• Index: Psychology

Informed by the latest clinical research, this is the first book to assemble a range of evidence-based protocols for treating the varied presentations associated with schizophrenia through Cognitive Behavioural Therapy

• Deals with a wide range of discrete presentations associated with schizophrenia, such as command hallucinations, violent behaviour or co-morbid post-traumatic stress disorder
• Covers work by the world's leading clinical researchers in this field
• Includes illustrative case material in each chapter

1

CBT for Psychosis: An Introduction

Craig Steel and Ben Smith

Introduction

Many readers of this book will recall a time when the predominant view within psychiatry was that talking therapies were not recommended for people diagnosed with schizophrenia. The past 10 years have seen a rapid expansion of an evidence base that has overturned this traditional view. Cognitive behavioural therapy (CBT) for schizophrenia is now recommended as part of routine clinical practice within a number of ­countries, including the United Kingdom and the United States. One consequence of this rapid rate of change is the need for widespread dissemination of this psychological intervention. Attempts have been made to meet this need through the publication of a number of treatment manuals, as well as an increase in the availability of training events.

The evidence base of CBT for schizophrenia was first developed through a generic intervention aimed at the relatively stable ‘medication-resistant’ group. However, as those readers who are trained clinicians will be aware, a diagnosis of schizophrenia is associated with a wide range of presentations. Consequently there have been recent developments within distinct protocols aimed at specific presentations and phases of the disorder. The aim of this book is to bring together these recently developed evidence- based protocols.

Although the interventions described within this book have key differences, which have been developed for specific target groups, they all rely on the basic engagement skills that are required when working with ­individuals diagnosed with a psychotic disorder. This chapter therefore aims to cover generic information, which will form the background to all following chapters. The chapter will cover four main areas: (i) a brief introduction to the symptoms associated with schizophrenia, (ii) the generic cognitive model of schizophrenia, (iii) generic clinical skills required when adopting CBT for schizophrenia, and (iv) a brief review of the evidence base of CBT for schizophrenia.

Schizophrenia

Schizophrenia is the most commonly diagnosed form of psychotic disorder. The most common symptoms are hallucinatory experiences and delusional beliefs. These are often referred to as the ‘positive’ symptoms of schizophrenia. The vast majority of CBT protocols for psychosis are aimed at these positive symptoms.

Hallucinations

Hallucinations are frequently considered to be sensory perceptions of stimuli that are not really there. While auditory hallucinations are the most common form, and have received the most attention from clinical researchers, they may occur within any sensory modality. Although the perceived auditory stimuli may be of general noises or music, they are most often in the form of a voice, or voices. They may be judged to originate from either inside the head or outside the head, may be experienced as male, female or alien voices, and there may be either single or multiple voices. The type of communication originating from the voice may come in many forms including ‘voices commenting’ in which the perceived voice makes frequent comments on the actions and thoughts of the voice hearer and ‘command hallucinations’ in which the voice-hearer is given direct instruction on how to act (see Chapter 2).

The work of Marius Romme and Sandra Escher in the late 1980s helped to highlight the relatively prevalent occurrence of voice hearing and to challenge the traditional psychiatric view, in which voices are the symptom of an illness. Their seminal work started with Romme, a social psychiatrist, and one of his voice-hearing patients appearing on a Dutch television programme and inviting viewers to contact them if they had heard voices. Hundreds of viewers responded with the majority having never received psychiatric attention. This event led to a research programme focussing on how individuals, who had heard voices, but remained outside the psychiatric system differed to those who had received a diagnosis (Romme and Escher, 1989).

Since then, several studies have suggested that around 3 percent of the population will experience hearing a voice at some point during their lives (Johns et al., 2004). These experiences will vary enormously within a number of different dimensions, and require careful assessment. One aspect of the voice-hearing experience which has received attention is that voice-hearers develop relationships with their voices, and that these relationships need to be considered during therapy. This perspective makes sense when one considers that an individual may have heard the same voice, which they attribute to a single person, every day for many years.

Perhaps the main impact of the work of Romme and Escher was to introduce the concept of ‘normalization’ into therapy. That is, to discuss with voice hearing clients the fact that there are many other voice-hearers, many of whom cope with or even enjoy their voice hearing experiences. This can often liberate a client from feeling trapped and alone with their experience. An introduction to voice-hearing groups can further facilitate this process.

The main issue for all therapists to consider would seem to be whether an individual’s voice hearing experience is causing them distress. Traditional psychiatry would have viewed all voice hearing experiences as a symptom of illness, which required treatment. However, recent work suggests than we cannot assume a voice-hearing experience is distressing. Given that therapy is aimed at the reduction of distress, it would seem than non-­distressing voices should not be a target for therapy. However, it should be remembered that voice-hearing experiences can fluctuate rapidly and that careful assessment is required.

Delusions

Delusions are the most common symptom associated with a diagnosis of schizophrenia, being present in around 75 percent of those receiving hospital care (Maher, 2001). A common definition of a delusion is that of a fixed false belief that is held in the face of evidence to the contrary. Delusional beliefs often need to be understood within the context of hallucinatory experiences. For example, a belief that someone is themselves the son of God may be fuelled by the experience of hearing a voice that tells them so. The most common of these beliefs are Delusions of Persecution, which tend to be associated with a paranoid presentation. Such delusions typically involve the belief that one is being spied on and/or is under threat due to some kind of organized conspiracy. The sufferer may feel threatened by government agencies, God or the Devil, their neighbours or by family members. Fenigstein (1996) described paranoia as a disordered mode of thought dominated by an intense, irrational, but persistent mistrust or suspicion of people and a corresponding tendency to interpret the actions of others as deliberately threatening or demeaning. Delusions of Grandeur are associated with a belief that one is a powerful and/or famous figure (e.g. Jesus). It is quite common for such individuals to also believe that they are being persecuted, and that the persecution is a result of their famous identity. Another form of this symptom is Delusions of Control, in which an individual believes their thoughts and actions are being controlled by an outside agent. A commonly reported experience within schizophrenia is that certain external events are perceived to contain special messages, for example within a news broadcast or within the lyrics of a song on the radio, and these are termed Delusions of Reference.

As with auditory hallucinations it is important to consider whether the symptoms associated with a diagnosis of schizophrenia are found within a non-clinical population, and if so what this means regarding clinical interventions. Several surveys have highlighted the prevalence of beliefs in the paranormal and other unusual beliefs within the non-clinical population. One important study highlighted how the beliefs of a psychiatric population could not be distinguished from those of new religious movements on the basis of content alone, but only by consideration of the dimensions of controllability and distress (Peters et al., 1999). There are also reports of a range of paranoid beliefs occurring throughout the non-clinical population (Freeman et al., 2005).

As with hallucinations, the therapist needs to consider whether the experiences an individual is reporting is distressing or not, and therefore whether they should be a target of therapy. While an individual may be expressing highly unusual beliefs, for example, relating to alien abduction, this may not be a cause of concern to them. Again, careful assessment is required.

Cognitive Behavioural Models of Psychosis

The early application of psychological models to schizophrenia was ­predominantly a simplistic application of learning theory, which gave rise to basic interventions. However, the development of cognitive behavioural models for affective disorders had a significant impact on psychosis research within the late 1990s. This work highlighted the extent to which the development and maintenance of a psychotic presentation could be understood with reference to psychological processes already associated with anxiety and depression. The traditional psychiatric view of ­schizophrenia was challenged in that therapists were encouraged to engage directly with the content of psychotic symptoms.

Early work was based on the view that the basic cognitive model could be applied to the symptoms of psychosis. Perhaps the primary rule within the cognitive approach is that it is not experiences which distress you, but the way you make sense of them. Thus, someone ignoring you is only upsetting if you believe that they saw you and that they ignored you on purpose. The same principle was applied to voice hearing experiences by Paul Chadwick and Max Birchwood (1994, 1995). They showed that the distressing affect and behaviour arising from hallucinations were not ­simply the result of the content of the voices, but reflected the voice ­hearers’ appraisal of the voices. They suggested that the hallucination is, therefore, seen as an activating event (A), which is then appraised by the individual in the context of their belief system (B), and which consequently leads to emotions and safety behaviours (C). The authors argue that this forms a cognitive-emotional-behavioural mechanism that maintains the belief in the power and dominance of the voice.

Two influential cognitive models of the positive symptoms of psychosis have since been proposed by Philippa Garety and colleagues (2001) and Tony Morrison (2001). Both of these models incorporate the role of ­negative core beliefs, hypervigilance for threat, scanning for confirmatory evidence and safety behaviours. In essence they concur that a psychotic presentation may evolve out of the presence of unusual experiences, with a critical factor being how these experiences are interpreted. Such ­experiences may include hearing voices, strong déjà vu, dissociative experiences such as derealization and intrusive thoughts or images. Psychosis is associated with such experiences being interpreted as negative, threatening and external and leading to hypervigilance and safety behaviours. For example, an individual who ‘hears a voice’, and decides that this perceptual experience is due to a lack of sleep is likely to have a different outcome to an individual who decides that the Devil is speaking to them with bad intent.

While many of the treatment implications of these two models overlap, one of the key theoretical distinctions is the extent to which the core ­unusual experiences are ‘normal’ or are anomalous biologically based ­phenomena. Garety et al. (2001) refer to the potential role of a genetic ­vulnerability for the propensity to some of these experiences, whereas Morrison focuses on the extent to which these phenomena are normal and that it is the interpretation of these experiences that is critical. In particular, Morrison focuses on the role of common ‘intrusive experiences’ such as intrusive thoughts and images that may form the basis of an unusual experience for some individuals. However, both models highlight the critical role of the appraisal of the unusual experience in determining whether an individual arrives at a ‘psychotic’ explanation. Therefore, while incorporating the generic cognitive model of anxiety and depression, these models also enable the formulation of the development of psychotic symptoms. A major strength of these models is that they incorporate a wide range of psychological processes that have been associated with psychosis, and have the potential to be flexible enough to enable the formulation of the ­heterogeneous range of psychotic presentations.

Cognitive behavioural models of psychosis (e.g. Birchwood, 2003; Garety et al., 2001; Morrison, 2001) all emphasize the central role of ­emotional dysfunction as a precursor, and consequence of, the symptoms of psychosis. These influential models also suggest that cognitive ­appraisals and perceptions concerning the nature of psychotic symptoms (including hallucinations) will influence the maintenance or recurrence of symptoms through coping responses, emotional dysfunction and cognitive processes such as reasoning biases.

CBT for Psychosis

In recent years a number of predominantly UK based clinical researchers have publicized the potential for an individualized formulation based ­cognitive behavioural approach to schizophrenia (e.g. Morrison, 2002; Kingdon and Turkington, 2005). Such an approach, as for other disorders, is based on the integration of developmental experiences and current beliefs and behaviours. The aim is to develop a personal account of the development and maintenance of currently distressing experiences that is less threatening than the beliefs that are currently held. This aim is particularly relevant for people diagnosed with schizophrenia, as their current explanations are usually limited to, for example, in persecutory delusions, either (a) ‘It is all true, people are out to get me’ or (b) ‘I am insane, I cannot trust my thoughts, I must take medication for ever’.

It is important to note that cognitive behavioural therapies for psychosis have developed in line with theoretical developments in our ­understanding of psychotic phenomena. CBT for psychosis aims to help an individual make sense of psychotic experiences by making links between emotional states, thoughts and earlier life events. Assisting people to make sense of psychotic and emotional experience by discussing psychological formulations can help them make connections between seemingly unconnected events or beliefs and disabling, distressing psychotic symptoms. The individualized, emotion-focussed nature of CBT for psychosis facilitates the engagement process. However, there are a number of generic issues that therapists need to be aware of when working with individuals ­diagnosed with a psychotic disorder.

Engagement within CBT

Fowler et al. (1995) suggest that CBT starts with a comprehensive ­engagement and assessment phase. This establishes a working collaborative therapeutic relationship, and allows for the collection of information that will inform cognitive-behavioural formulation. Specifically, therapists must be sensitive to issues of mental state, active hallucinations and ­specific delusional beliefs when engaging, assessing, sharing formulations and conducting interventions.

The clinician should be mindful that a voice hearer, for instance, may initially not wish to discuss their experiences and that a level of trust may first need to be gained. Problems for engagement may include the voice hearer being concerned that they may be sectioned or have their medication increased if they discuss their voices. This issue can be addressed overtly with the clinician stating whether or not these assumptions are correct. It may also be the case that the voice is telling the voice hearer not to discuss anything with the clinician, and may even make threats of violence or death. The clinician will not be in a position to know...

Table of contents

• Cover
• Title page
• Copyright page
• About the Editor
• List of Contributors
• Preface
• Acknowledgements
• 1 CBT for Psychosis: An Introduction
• 2 Cognitive Therapy for Reducing Distress and Harmful Compliance with Command Hallucinations
• 3 CBT for Post-Traumatic Stress Disorder and Psychosis
• 4 CBT for Individuals at High Risk of Developing Psychosis
• 5 CBT for Medication-Resistant Psychosis: Targeting the Negative Symptoms
• 6 The Challenge of Anger, Aggression and Violence when Delivering CBT for Psychosis: Clinical and Service Considerations
• 7 CBT for Relapse in Schizophrenia: A Treatment Protocol
• 8 CBT to Address and Prevent Social Disability in Early and Emerging Psychosis
• 9 Group Cognitive Behavioural Social Skills Training for Schizophrenia
• 10 Brief Acceptance and Commitment Therapy for the Acute Treatment of Hospitalized Patients with Psychosis
• 11 Improving Sleep, Improving Delusions: CBT for Insomnia in Individuals with Persecutory Delusions
• 12 Compassion Focused Group Therapy for Recovery after Psychosis
• Index