CBT workshop for Carers by Douglas Turkington on May 23/24
I've written the report below based on my notes from attending the CBT workshop. If you have any questions about the material or about the workshop, please contact me at mentalhealthfamilies@gmail.com
Our monthly meeting will be on June 9th at 7pm at The Link in Smiths Falls, 88 Cornelia Street. We will discuss the workshop and any other topics you would like to cover.
Cognitive Behaviour Therapy for Psychosis by Douglas Turkington—Report/Notes
Rumination is thinking about the past and it fuels paranoia.
Worrying is thinking about the future and it doesn’t keep you safe.
When you catch yourself doing either, it is best to set a time to worry or ruminate. Postpone all worry and rumination till the time you’ve decided to do it. Usually less likely to feel important to do it at that time.
Hallucination is fairly common in people who are grieving, sleep deprived, etc. Does not mean you are psychotic.
Make sense of the psychosis—ask about the voices, work with the beliefs to help the voices settle, list possibilities of what the voices/delusions are saying and work at why they might be saying this.
Do Reality Testing—Work with person to help develop an experiment to help test their delusion or voices. Set up an agreement on what certain outcomes would mean in advance of doing the experiment.
Peripheral questions (shows interest without challenging)
Personal Disclosure-share your own experience
OCD/Psychosis— belief that they caused things to happen due to their thoughts/actions.
Befriending vs CBT
Both worked very well. Befriending had best effect on delusions/paranoia rather than voices and negative symptoms. Once befriending ended, all delusions came back. Medical community starting to think that befriending for 20 sessions before beginning CBT is best outcome.
80% of people with schizophrenia respond to CBT. People with hallucinations are particularly responsive to CBT. CBT is helpful in getting patient to take the medication and then become able to come off the meds. Kapur believes that antipsychotics encapsulate the delusion and pushes it below the surface and when antipsychotics are stopped the delusion will return. Need therapy to deal with the delusion either with or without meds.
Voices are often triggered by certain noises, particularly white noise. Noises like: birdsong, vacuum, traffic, air conditioner. Isolating when the voices start can help to narrow the possible triggers. Earplugs can often help with voices.
Helping the person with voices and unusual beliefs: write down the voices, ask others if they can hear them, localize the voices (where do they come from?), audiotape the voices, test out explanations (with the person, not in a challenging way, but by working with the person to help them), take a baseline voice diary (this will help identify patters so you can help find a trigger), help the person establish how they feel on and off the meds. Help change the balance of power: person vs voices, writing down the voices and shredding if they are too shameful or painful to share.
Teaching of specific coping skills is not happening!!! Telling a person to do something is not the same as demonstrating how to do it well and checking how well they are doing the coping technique once they have started. Very important to improve the coping skills.
Patients who cope well: believed they are stronger, experienced more positive voices, had less command voices, set limits on their voices, listened selectively, talked to others about their voices.
Patients who do not cope well: saw themselves as weaker, experience more negative voices, had more command voices, did not dare to set limits on them, tried to escape from the voices by using more distraction techniques.
Command (Imperative) voices: Voices that tell someone to go DO something. If someone walked straight up to you and hit their fist into their hand, they may have had a command voice tell them to go punch you and they were able to disobey the command at the last second.
Coping strategies for hallucinations and delusions:
Distraction: listening to music, playing the guitar, attention shifting, art, walk, pets, writing, dvd
Focussing: sub-vocalization, deep breathing, rational responding, schema work (attention shifting—Adrian Wells MCT—metacognitive therapy)
CBT is very helpful in non-compliance issues. Average person on antipsychotics takes their meds 2 out of 7 days. CBT can help the person understand why they are and aren’t taking their meds. “what is the first thought that occurs to you when you first look at the pill bottle?” helps gain insight into their beliefs and feelings about their pills.
Medication Non Compliance
#1 reason to comply with taking meds is that the prescriber is liked by the patient!!!
If the person has selected their own meds based on side effect information provided by prescriber, they are more likely to be med compliant.
All people have a tendency to focus on the side effect rather than the benefits. Need to review benefits regularly to ensure at least equal focus on benefit and side effect.
Greater healthcare provider turnover promotes relapse. Teams need to look at having a limited number or one main person who connects with the patient.
Placebo level results should NOT be a reason to use a med—especially one with lots of side effects.
Negative symptoms: Affective flattening (difficultly in communicating or expressing emotion), Alogia (slowness to respond, and not much to say), Avolition (Get up and go has gone, little motivation/social withdrawal), Anhedonia (Unable to get pleasure), Attention deficits (poor concentration/memory)
CBT is most effective at treating the positive symptoms of psychosis, IE) the hallucinations and delusions.
There are different types of psychosis.
Drug induced basis
Traumatic basis-CBT can help with the hallucinations/delusions and medication compliance, meds are not usually needed long terms if trauma is treated.
Biological basis-more likely to need to remain on meds long term, primary negative symptoms, most likely to be medication responders where CBT can be helpful in medication compliance.
Emotional neutrality in the home is crucial for recovery. Don’t push too hard/no nagging. Demonstrate that they are accomplishing something as long as they are enjoying it, even if it is lying on the bed. Emphasis is always on the attempt of the activity rather than on the completion. Start small (go to bed rather than sleep on couch) Work to re-establish social contacts daily chores. Start with attempting, then move to completion, then to mastery. Have the person make a list of their daily activities, and begin filling in daily logs of their activities.
Resources
Provider resources
High-Yield Cognitive-Behavior Therapy for Brief Sessions: An Illustrated Guide by:
Jesse H. Wright, M.D., Ph.D.
Donna M. Sudak, M.D.
Douglas Turkington, M.D.
Michael E. Thase, M.D.
Cognitive-Behavior Therapy for Severe Mental Illness: An Illustrated Guide by:
Jesse H. Wright, M.D.
Douglas Turkington, M.D.
David G. Kingdon, M.D.
Monica Ramirez Basco, Ph.D.
Family caregiver resources
Back to Life, Back to Normality: Cognitive Therapy, Recovery and Psychosis by:
Douglas Turkington (Author), David Kingdon (Author), Shanaya Rathod (Author), Sarah K. J. Wilcock (Author), Alison Brabban (Author), Paul Cromarty (Author), Robert Dudley (Author), Richard Gray (Author), Jeremy Pelton (Author), Ron Siddle (Author), Peter Weiden (Author)
Treating psychosis website has numerous links and resources.
