0 2013 Americon P.ychological Associocion 0033·3204/13/SI2.00 001: 10. 1037/a0032S97

P.ychotherapy 2013, Vol. SO, No. 3. 4S8-463

Clinical Process Examples of Cognitive Behavioral Therapy for Psychosis Harry J. Sivec and Vicki L. Montesano Northeast Ohio Medical University

Interest in the practice of Cognitive Behavioral Therapy for persistent psychotic symptoms (CBT-p) has increased dramatically in the last decade. Despite the widespread interest, it remains challenging to obtain adequate training in this approach in the United States. This article provides a few hypothetical examples of the types of interventions commonly used in CBT-p. We provide information about the theoretical basis for the techniques and related research support. We also provide references that offer more detailed discussion of the theory and application of the techniques. Keywords: cognitive behavioral therapy for persistent psychotic symptoms, techniques, clinical process

The results of several meta-analyses have provided evidence for the efficacy of Cognitive Behavioral Therapy for Psychosis (CBT-p; see Wykes, Steel, Everitt, & Tarrier, 2008). The results of effectiveness studies have been mixed (Farhall, Freeman, Shaw­ yer, & Trauer, 2009); however, a recent study (see Lincoln et at., 2012) has provided support for the effectiveness of this approach in routine clinical practice settings. In this article, we will provide a brief outline of one model for CBT-p followed by examples of hypothetical exchanges between therapist and client designed to highlight certain process elements that we believe are essential to effective CBT-p. The case examples do not represent verbatim examples from actual sessions and are not specific to any one client. Although there is no singularly agreed upon model for delivering CBT-p, there are several common phases (See Sivec & Montesano, 2012) and a variety of attitudes and techniques con­ sidered essential to this approach (Morrison & Barratt, 2010). We provide an example of the model that we use in practice for CBT-p that is based largely on the work of Kingdon and Turkington (2005) but incorporates the work of other clinicians and research­ ers working in CBT-p. The first phase is dedicated to the engagement process and how the clinician relates to the client. It is important to take active steps to promote safe and positive interactions, bearing in mind the particular challenges that psychotic symptoms place on forming relationships (see Chadwick, Birchwood, & Trower, 1996). As the client-therapist alliance is developing, the objective of the next phase is to develop a shared understanding of the client's concerns. The shared understanding is often referred to as a "formulation," which is a dynamic model that guides the subsequent treatment strategies.

The next phase of CBT-p addresses symptom management and is characterized by discussions that focus on improving functional coping and decreasing avoidance and safety behaviors (see Tarrier, Harwood, Yusopoff, Beckett, & Baker, 1990 for research on coping strategy enhancement). During this phase, the therapist assists the client in considering alternative perspectives for their symptoms and begins to engage the client in reality testing exper­ iments. Reducing distress with different coping strategies and beginning to "reality test" the client's beliefs about their experience sets the stage for the next phase. In this phase, the therapist explores the beliefs and assumptions that underlie and influence the client's psychotic symptoms (Nelson, 2005}. It is often these long-held beliefs that perpetuate the psychotic symptoms. For this article, we will emphasize three areas of clinical pro­ cess: Engagement phase interactions as well as techniques com­ monly used to address delusions and hallucinations. Engagement Phase: Using a Normalizing Rationale and the Stress Vulnerability Model

To facilitate the engagement process, therapists are encouraged to pay careful attention to the particulars of location, the pace and duration of sessions, and the timing of intervention (Kingdon & Turkington, 2005); flexibility is critical. The goal is for the client to feel comfortable to tell their story. From a process standpoint, one strategy for reducing anxiety and stigma associated with the experience of psychotic symptoms is to provide information that serves to "normalize" the client's experience. To normalize psy­ chotic symptoms means to describe the experience in terms of other common human experiences (e.g., sleep deprivation} and to point out the predictable quality of symptoms (e.g., the role of stress and coping). Normalizing typically happens in three different ways: provid­ ing information and education about psychosis to reduce cata­ strophic thinking (e.g., examples of famous people who have heard voices and cope well; the idea that psychotic symptoms exist on a continuum from relatively common to more rare and distressing); providing a rationale that all symptoms (both physical and mental health) are affected by a balance between vulnerability and stress (and by improving coping one can lower distress); and offering

Harry J. Sivec and Vicki L. Montesano, Best Practices in Schizophrenia Treatment (BeST) Center, Department of Psychiatry. Northeast Ohio Med­ ical University. This article was supported in part by a grant to the BeST Center from The Margaret Clark Morgan Foundation. Correspondence concerning this article should be addressed to Harry

I. Sivec, Best Practices in Schizophrenia Treatment (BeST) Center. Department of Psychiatry, Northeast Ohio Medical University, 4209 State Route 44, P.O. Box 95, Rootstown, OH 44272. E-mail: hsivec@ neomed.edu

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appropriate personal disclosures to help reduce the client's expe­ rience of isolation and alienation. Case 1: "Cecilia" is a 40-year-old woman who lives with family and has been bothered by hearing voices for many years. At intake, we know that the voices call her names and tell her to hurt herself and that she gets enraged at times when hearing the voices. She does not like to talk about hearing voices. During sessions, she mainly focuses on her desire to find a job. The exchange below highlights pacing and giving control to the client. T: I remember from our last session that it is very important for you to work and I wondered where we can start with that goal? C: I just need to get a job, but I can't concentrate; hear voices talking to me trying to get my attention .. . T: Can you tell me some more about that? C: I don't know who they are, but they bug me ... T: What do they say? C: Mean things about me; want me to do things; I don't like to talk about it.

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represent a person or persons doing this to her while asking clarifying questions. It is important to start with the client's per­ spective first and avoid directly challenging the client's explana­ tion for the experience. The therapist can then provide education about schizophrenia (this perspective was already raised by the client's mother) as one of many possible explanations for what the client is experiencing. Psychoeducation should be carefully se­ lected so that it offers a realistic sense of hope. It is our experience that education alone often has a limited influence on the client's perspective. We find it helpful to talk about factors that affect voices, with an emphasis on stress vulnerability (see Zubin & Spring, 1977), coping, and controllability of symptoms. T: One thing l have learned from the people l work with is that certain things make the voices louder and quieter. C: What do you mean? T: Well one thing that seems to affect hearing voices is stress. Maybe you have noticed this.For example, if we are under a lot of stress ... new job, car breaks down, get into an argument ... a lot

T: Sounds like it's awful to hear all this negative stuff said about

more than we typically face, our body and mind react with dis­

you.I don't want to press this if it is too upsetting, but it might be

comfort.For some people, they get headaches, back problems.For

helpful if I knew just a little bit more to see if I can understand

others who hear voices, the voices may get louder and more

what is happening. Would that be ok? (ask permission and give

negative.Does that make sense to you?

client control of disclosure). C: All right. T: If it starts to get too upsetting just let me know, and we can work on something else When does this happen? C: At home, mostly at night. But it happened at work a lot in the past too. It caused problems there. I get upset. T: I know that working is important to you. Can you tell when

C: Yeah. I get headaches when I am stressed.I never thought about my voices getting louder too. T: It's something 10 think about. One other thing that affects stress level is sleep.When people lose too much sleep, the voices can really be upsetting. In fact, if any of us were deprived of sleep for a long enough time, we could begin 10 hear voices (stress

vulnerability model could be further explained).

it happened at work . . .

C: Wow. l do have sleep problems.

The therapist can explore different aspects of the experience (e.g., who it is, when it happens, what changes it, do other people hear the voices), depending on the client's comfort level in de­ scribing the experience. The therapist ties the initial question to the client's goal of wanting to return to work to reinforce the intent to help the client with her goal. The next step is to get a sense of the client's understanding of what causes the voices.

T: For most of us, when we don't sleep well, it can really affect

T: Sounds very upsetting.Do other people hear what you hear? C: No. My mom says it's "voices" and to ignore it; she thinks I am crazy.

our bodies. I recently took a long trip and found that I was very groggy and confused after not sleeping for 20+ hours, and it was really hard to put my thoughts together (mini-self-disclosure). The good news is that when sleep gets better, we often feel better and think more clearly. C: I would love to sleep better. T: Maybe we can make that part of our work as we go along? The other thing is that people sometimes think that if they hear voices they won't be able to do anything else like work or socialize.

T: What does she mean by that?

This is also not really accurate. Do you know anyone else who

C: I don't know, I'm not crazy or stupid ...Someone out there

hears voices?

is doing this.

C: Some people here at the agency, but not really.

T: So let me see if I got this: You hear people saying nasty

T: Would it surprise you to learn that there are many people

things, mostly at night, but other times too, like at work, and your

who hear voices and work, go to school and do things in life? In

mom says it is a voice and that she thinks you are "crazy?" (repeat

fact, there are some famous people who have talked about living

back what the client says and try for "word perfect accuracy" rather than paraphrasing; Kingdon & Turkington, 2005).

with voices. I saw something recently in a magazine on Brian

C: No, she didn't actually sa�, l was crazy. but that I am schizophrenic.

Wilson. Do you know his name from the Beach Boys? C: Yes. T: Good. Well, he was interviewed with his wife and kids. In the

T: So your mom says it is schizophrenia. It doesn't sound like

article, it mentions that he heard voices for much of his adult life.

you are so sure about that, but you're also not sure why this is

C: Even when he was playing with the band? How did he do it?

happening? C: I just want to get back to work.

T: I don't know all the details, but I know he had support and that when he was reminded that the voices wouldn't hurt him, he

T: Sounds like this is very frustrating. Maybe we can talk about

did better. Maybe we could look into this article if you are

what happened in the past so that we can understand why it is

interested? l also have a list of other famous people who have

happening and what we can do to help you get back to work.

heard voices.

The therapist takes some time to explore the client's explanation and all the reasons the client provides that suggest that the voices

This conversion could lead to several "next steps" in the therapy process; the therapist could follow up with the concerns over sleep

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and focus on sleep hygiene, cognitive strategies for sleep, and so forth; the therapist could also provide information about other famous voice hearers and begin to talk about how they coped with their experiences. Both approaches attempt to "de-catastrophize" the experience of voice hearing, to invite and support talking about voices, and to introduce the idea that there may be several ways to deal with voices. Research Evidence

The research evidence supporting the use of "normalizing" strategies is based mainly in clinical experience. One study con­ ducted by Dudley et al. (2007) reviewed therapy transcripts of clients who responded to CBT-p compared with those who did not respond. They found that ratings of sessions of those who re­ sponded to CBT-p contained more items suggesting engagement, a collaborative relationship, and included specific items such as sharing education about schizophrenia and clinician self­ disclosure. Techniques and Process: Working With Delusions

As we mentioned earlier, before moving into work with delu­ sions, the therapist needs to lay a foundation of trust and collab­ oration. Without this foundation, the techniques may miss the mark, resulting in miscommunication on the therapist's part and potential frustration on the client's part that may hinder the ther­ apeutic process. Our client's delusional systems are typically complicated with an overarching theme that can be considered the primary delusion. In addition, the client often develops multiple peripheral delusions that support the primary delusion. From the cognitive model per­ spective, the person interprets an anomalous experience with a delusional belief that is sustained by the emotions tied to the experience and a variety of reasoning and attributional biases that reinforce and maintain the delusional beliefs (see Beck, Rector, Stolar, & Grant, 2009; or Kuipers et al., 2006). Delusions are not always apparent, and clients are not always forthcoming with details, which reinforces the need to establish trust and collaboration. A helpful analogy is to think of a delusion like an iceberg that has multiple layers. The tip of an iceberg is above the water and is visible to the eye (e.g., actions, behaviors, impact on the environment), while the majority (90%) of the iceberg (i.e., delusion or belief) is under water or hidden. Icebergs are also typically unstable and can move based on a number of factors above and below the water line. Likewise, delusions are maintained by a balance of reinforcing factors (internal and exter­ nal). A delusion can be "moved" by changes in behavior (at the surface) as well as by "chipping away" at the beliefs that underlie the behavior. When a client's behavior or environment are amenable to changes (e.g., client agrees to increase activity level), these efforts toward more functional coping may lessen the impact of a delu­ sion. At a deeper level, the therapist is also encouraged to fully listen to the details of the delusion(s) and search for the peripheral delusion(s) that has the greatest potential for modification (or ·'chipping away''). Through Socratic questioning (Padesky, 1993), the process for working with a delusional belief involves gathering data on the

primary and peripheral delusion(s), looking for and/or gently in­ troducing areas of doubt, examining the information from different perspectives with the client, and asking the client to formulate a plan to test the different perspectives. Including allied staff members who work with clients in the community can be very helpful in working with delusions. During therapy, the goal is to assist the client in generating and testing alternative perspectives or explanations about the delusion. After identifying the different perspectives, it becomes important to check out the client's thoughts. Some of this work is done in session. It is also important to extend this work into the commu­ nity. However, many times, the therapist is unable to leave the agency to help the client reality test a delusion in the community. Without allied support, the burden to engage in this type of evidence-checking activity rests with the client who often feels vulnerable or anxious and may not follow through between ses­ sions. Case 2: "Amy'' is a 23-year-old woman who has been strug­ gling with paranoia for the past 3 years. She no longer leaves her home and spends the majority of time sleeping, up to 16 hours per day. Amy lives with her mother and brother. Over the past few years, her friends have slowly lost contact. Amy believes that she can hear people talking about her as they walk down the street or drive by the house. She also believes that these people want to inflict harm. The following is an exchange that is intended to highlight work with a delusion along with the importance of including allied staff, when possible, in the therapeutic process. T: Can you tell me about the people who walk or drive down the street? What do they say about you? A: l am not sure, but it is bad. T: Do you know any of these people? A: I only know two of them. They always drive down the street and talk about me. They talk to me from their houses and try to control my mind. T: How are they able to do that? A: It is some type of mind control. but l feel it all the time. No matter what l do, they are in control. T: Are they able to hear our conversation? A: I don't think they know I am here. If they do, then they will punish me. They also tell everyone abolll me.It is so embarrassing. Every time I walk into a store, people look at me.

The therapist uses Socratic questioning to explore the connec­ tions that the client is making and determines that the main delusion focuses on the two young men and their ability to control her mind. Thinking about the iceberg analogy, the therapist can explore the possibility of having the client complete an activity log between sessions. This assignment increases the client's awareness of her activities (visible-behavioral effects of the delusion and areas to change). In addition, the therapist can also identify an aspect of her belief (under the surface) that the client may consider testing in the community with her case manager (e.g., how often people look at her and under what conditions). The exchange below points out how to begin to "chip away" at the client's belief by identifying current areas of doubt, expanding client's perspec­ tive, and working with another person to check the evidence. T: Thank you for being so open with me during our last session. I realize that it took a lot of courage to share that with me. Something that you said really stood out. When I asked you if they could hear us talking. you said that you weren't sure

(pointing out

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CBT-P CLINICAL PROCESS an area of doubt already expressed by the client). Has that changed

in ways to guide the client and what to help the client record for the

over the last week?

next meeting.

A: No, I don't think that they were able to hear us because they did not try to punish me.

T: Tell me about the experiment. A: At first, Lisa and 1 just walked into the front door. I was

T: That's really interesting. It sounds like there might be times

shaking really bad and

was

afraid to look up. Lisa was really

when the two men are not trying to control you. Can you think of

helpful, because she talked to me the whole time about the weather

other times during the day when you don't feel that they are trying

and other stuff She told me that we could walk right out if I wanted

to control you (broadening client's points of reference)?

to and I did. We sat in the parking lot for a few minwes, and talked

A: . Well, it feels like they try their hardest in the morning and right before I go

ro

a little.I told her that I wanted to try it again. I didn't look up until I walked through the door.No one was by the door, so I relaxed

sleep. I think there might be some afternoons when they leave me

a little. We were probably in the store for about 15 minutes. Only

alone.

two people looked at me that whole time.

T: Ifthey leave you alone in the afternoon, is it possible that they may not be telling others about you at that time?

L: But the only reason why the one person looked at you was b�cattse you almost bumped carts.

A: I guess.

A: Oh, yeah, that's right. When we walked by the second person

At this point, the therapist could explore the implications of her

who looked at me, Lisa asked me a few questions that made sense.

observation that the client is not bothered "all the time." The client

L: I asked her to think of other reasons why the person might

can then be encouraged to study the experience in a somewhat

have looked at her.He only looked at her for a second. so it wasn't

objective manner to better understand what may be affecting her.

like a stare.I asked her to think about what he might be thinking

This tactic helps the client to build on the nascent idea that she is

that wasn't about her.

not watched continuously. The next exchange works on a different,

A: And it made sense to talk abollt it, because there are times

but related, thread of the delusional system: that is, the idea that

that 1 look at other people but I am thinking about something

everybody looks at her and the reason is that they know about her

else ... The experiment in the community gave the client an opportunity

and think badly about her.

T: Amy, one thing you mentioned early on was that you have

to test her belief that "everyone looks at me." The therapist can

been frustrated that you haven't gone to the store in a long time.

then work with the client on developing alternative explanations

Let me know if I am wrong, but you mentioned that you wallted to

for why others may look at her. A next step would be to guide the

get out in the community more, like shopping.Is that right?

client to continue the process, spending longer periods of time in

A: Yes, but it is so hard because everyone looks at me.

the store, with or without the case manager (depending on the

T: So you want to get out more, but it's hard. I was also

client's confidence and progress), and to continue to test thinking.

wondering if you would be willing to try an experiment in the

The therapist then helps the client to develop a different more

community with Lisa (client's case manager within the agency). A: I'm not sure ...

realistic set of expectations for the next time the client goes to the store to replace the previous delusional belief.

T: I think that we could work together to develop a plan that might help you get back out in the community. I was thinking of asking Lisa, your case manager, to take you to a store one

Research Evidence

afternoon this week. The goal would be to check out how many

The research on CBT-p with delusions has shown some inter­

people are looking at you and what happens when you are in

esting patterns. Meta-analyses conducted by Pfammatter, Junghan,

public. We would do this in small steps. and you would be in

and Brenner

charge of the experiment-like what store you go to, how long you

a therapy trial, but a significant positive effect when clients are

(2006) described nonsignificant benefits at the end of

stay, things like that.The first step would be for you and Lisa to

reevaluated several months posttreatment (small to medium effect

just walk through the front door of the store, look around briefly,

size). This pattern was evident in several, but not all, studies. One

and leave. I would ask you to talk to Lisa about whether or not

possible reason for this finding is that delusions may require more

anyone looked at you. We could start there and then see if you can

time to change relative to other symptoms (e.g., hallucinations,

slowly increase the amount of time that you spend in the store and

anxiety). Also important in the above example is the flexibility in thinking, which has been suggested to be a factor associated with

see what we learn. Let me know what you think.

1997). Finally, the use

A: I can give it a try. Can Lisa do this?

positive response to CBT-p (Garety et al.,

T: We will check with her next. The idea is for you to begin to

of allied mental health staff allows for the possibility of improved follow-through with homework assignments and reinforcement of

take steps to reach your goal with some support. The therapist asks Lisa, the case manager. to come into the room

new learning.

at the end of the session and explains the plan. Emphasis is placed on making observations of what happens in these situations. If the client is willing to keep working in this way, they will go back into the store for a longer period of time. The therapist is transparent and explains that the ultimate goal of the experiment is to have the client look around at other store patrons to see whether they

are

Additional Techniques and Process: Working With Hallucinations There are two primary approaches to working with hallucina­ tions: Check:ing the effectiveness of different coping strategies and

look:ing at her. In this situation, it is important that the case manager

reality testing experiences. Coping strategies assist our clients in

has developed a supportive trusting relationship with the client before

managing symptoms and range from harmful (e.g., drug and alco­

participating in this activity. The case manager should also be trained

hol use) to effective (e.g., putting on headphones to listen to music,

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SIVEC AND MONTESANO

challenging the claims of the voices). One of the goals of working

T: Yes, you schedule

if a

a

time. And-good question-wlwt would

with hallucinations is to explore with the client current coping

you do

strategies that are used, search for past strategies that have been

btiSY and you knew you had set a time to meet with them later?

helpful, and explore new strategies. The example below focuses on different ways to improve coping with voices. Case 3: "Joe" is a 59-year-old man who has been married for 30 years and has one son ("Dave"). Dave and his wife have a

family or friend tried to interrupt you when you were

J: I guess I would tell them to wait until that time. T: That's right. Could you do the same with the voices? Is it worth a try? J: Sure.

5-year-old daughter ("Zoey") who refused to go to her grandpar­

T: Anything else fr·om that list?

ent's house over the past week because she has become afraid of

J: What is this "rational response" to the voice?

Joe (when he yells at the voices). During the third session, the

T: Another good one.It asks you to think about whether whar the

therapist examined attributions related to the voices and learned

voices are saying is accurate and how you might respond. If the

that Joe enjoys listening to them talk; however, there are times that

voices say you are smoking too much and you are bad, what could

two of the voices become abusive. The therapist realizes that the

you say that is more accurate?

goal of this session is to work with Joe on helping him stay in the present and lessen the negative impact of symptoms. T: Tell me what happened with Zoey over the past week.

]: She told my son that I scared her because I was talking to the boogey man. Two of the voices were yelling at me because I was smoking too many cigarettes.They were downright nasty. so I was yelling back. The other two voices were trying to make me feel better.

J: Well, I know smoking is not good for me. but I am trying to quit and I have cut back. T: That's right. You know it is not good for you and you are trying to cut down. If a habit like this is not healthy. does that make you bad? J: No. and I am trying to stop smoking as much. T: Exactly! Do you think it might be helpful to remind yourself of that fact when you hear the voices? Maybe write it down?

T: May I point something out to you?

J: I guess I could.

J: Maybe.

The therapist can help the client write out a "coping card" that

T: I have noticed during our conversations that you appear

reminds him of the strategies that he can try during the upcoming

distracted at times. You have also talked back to the voices when

week. Meta-analyses examining the benefits of CBT-p with hal­

we have been together.I am concerned that when you talk back to

lucinations generally indicate a modest positive impact, but that

the voices, you aren't a parr of what is happening right in from of

the benefits may not persist at 6 to I 2 months posttreatment

you.I am also concerned that it might make you stand out in public

follow-up (see Pfammatter et al., 2006). Although several studies

and push people away. It sounds like this is what happened with

list benefits associated with using distraction and focusing-based

Zoey.Please let me know if I am wrong.

coping strategies, there appears to be no clear long-term advantage

J: I think you are probably right ...

to a single method (Haddock, Slade, Bentall, Reid. & Faragher,

T: When we first started this work. you completed a voice diary. What did you leamfrom this activity?

I 998). However, having a variety of strategies for coping with voices has been one important factor reported by those who see

J: Well. that the voices talk to me the most right after lunch.I

themselves as coping well (see Romme, Honig, Noordhoom, &

would chain smoke and they would yell at me that smoking was

Escher, 1992). From our standpoint, it is most beneficial to explore

bad and that I was bad.

a variety of potential strategies that help clients to experience the

T: I asked you if you would be willing to eat lunch and then sit

ability to influence or control their voices.

down in front of the 1V. You told me that the voices didn't talk to you then, is that right?

Conclusion

J: Uh huh. T: So by changing one of your behaviors. it had a big effect on the voices. /wonder if you could see if there are other things you can do to see if they will stop talking to you when Zoey is over. That way. she won't become afraid of you. Do you think it would be worth a try? J: /love Zoey, and it really hurts that she is afraid of me./will try anything ... T: I have a list of coping strategies that other people have found helpful in dealing with their voices. Maybe we could look at this list and see if there is somethbzg else you can try over the next week? . J: What does this mean. "scheduling a time for the voices?"

Overall, our goal was to highlight a few process elements that we believe have a positive impact on treating persistent psychotic symptoms. It is our belief that it is absolutely critical to develop the therapeutic alliance to effectively apply any technique. Proper use of engagement and normalizing strategies can help to reduce resistance and stigma and provide one entry point for discussing symptoms. Techniques for use with delusions essentially begins with listening to the client's understanding of their symptoms, looking for places where doubt already exists, and finding ways to introduce alternative perspectives. Finally, we discussed methods for introducing different coping strategies for voice-hearing with the goal of empowering the client to better understand how to influence and control their experience of hearing voices.

T: You picked out a good one! This one has to do with setting a specific time of day and amount of time

to

try this? J: Just schedule any time, like an appointment? What if the voices act ttp before that time?

References

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Some people have found this helpful. Do you think that you could

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Received February 4, 2013

10.1093/schbuVsbpiiS

Accepted February 5, 2013 •