Cognitive Behavior Therapy and Psychosis - Coursework Example

Cognitive Behaviour Therapy and Psychosis by SID # Cognitive Behaviour Therapy and Psychosis Cognitive behavioural therapy (CBT) is a type of therapy that aims to help one to manage his/her problems by changing how they think and act. The principles are that the therapy requires a thorough therapeutic relationship in a two-way effort between the qualified, supportive and empathic CBT practitioners and the client; and relies on the inductive method, a scientific methodology using logic and reasoning (Whitfiled and Davidson, 2007). It is brief, time-limited and uses between-session practices as a central feature. Several models and theories of CBTs exist, but they all use two general techniques. First, there is a discussion between the therapist and the patient around for and against negative beliefs, and secondly by change in behaviour by the client to see what happens. But the underlying central insight is that stimulus generates thought and thought generates emotions. CBT is a process of teaching, coaching, and reinforcing positive behavior. It helps people to identify thoughts and emotions that are linked to behavior (Fowler, Garety, and Kuipers, 1995). Apart from face-to-face CBT treatment, internet and computer based delivery of CBT treatments are also available. Many disorders have been shown to respond well to CBT, but not everyone benefits from it, and response may be at different levels in the responders (Blenkiron, 1999). Pharmacotherapy is also available for these patients but Aaron T, Beck says “I think that in the 21st century, psychotherapy will flourish. I don’t think that pharmacotherapy is going to take over the field completely (Beck, 1997). CBTs have been used for several problems and disorders like all forms of depressions, bipolar disorder, bulimia nervosa etc. Psychosis, which can precipitate due to several medical conditions, is also treated with CBTs. There is widespread agreement that onset of psychosis follows adverse social environment, life events, substance abuse or periods of isolation. At onset of this disorder the most prominent symptoms are delusional beliefs and hallucinations. The core symptoms manifests as disturbances of cognition in basic cognitive process concerned with processing of information, which results in anomalies of perception and experience of the self, for example hallucinations. It also manifests in conscious appraisal and judgments leading to unusual beliefs or delusions. Cognitive psychology suggests evidence of disruptions and biases in processes that are thought to contribute to the development and persistence of psychotic symptoms (Garety, Fowler and Kuipers, 2000). Several theories have been put forward to explain the symptoms seen in psychosis. Some have suggested that the anomalous experiences associated with delusions result from cognitive neuropsychological deficits. They do not rule out brain dysfunction (Hemsley, 1994). While some argue that there is no single pathway to delusions. In some cases, one type of the process may explain the presence of the symptoms while in others symptoms may be the final common pathway of several interacting processes like biological, psychological or social (Garety, Fowler and Kuipers, 2000). Cognitive accounts consider how psychotic experiences may be negatively appraised by an individual. These experiences may result in emotional disturbances, depression, anxiety or negative evaluation of self, which jointly contribute to the development and maintenance of symptoms of distress. The hypothesized role of emotional processes such as depression and anxiety in the onset and maintenance of psychosis leads to the direct application of CBT for this problem (Freeman and Garety, 1999). In general the aim of CBT for people with psychosis is three fold according to Fowler, Garety, and Kuipers (1995). First, to reduce the distress and disability caused by psychotic symptoms, second, to reduce emotional disturbance, and thirdly, to make the patient understand psychosis with an aim to promote his/her active participation in reducing relapse and social disability. Garety, Fowler and Kuipers, (2000) have proposed 6 stages of CBT for psychosis. They are: 1. Engagement and assessment for building and maintaining a therapeutic relationship 2. Coping Strategies after assessing current distress and symptoms 3. Help patient develop a new understanding of the experience of psychosis 4. Working on delusions and hallucinations 5. Addressing negative self-evaluations, anxiety, and depression 6. And finally, managing the risk of relapse and social disability In the initial stages of therapy, people with psychosis may be angry, suspicious or in denial with the relevance of therapy with their problem, but this is the period of paramount importance where the client should feel totally understood. The therapist should accept client’s belief and emotions and start by working from the client’s own perspective. The initial stages should be tolerable, collaborative and gentle. Hallucination or delusion during this period should be acknowledged and discussed with a gradual transition from empathic listening to more structured interviewing to establish the factors that led to the onset of psychosis. Cognitive coping strategies follow the initial interviews of the client. Cognitive and behavioral strategies like activity scheduling, anxiety reduction, and attention control are implemented which can help cope with episodes of hearing voices, anxiety or feeling suspicious (Fowler and Morley, 1989). Here the therapist tries to manipulate factors contributing to symptom maintenance with an aim to generate feelings of control and hope to provide practical help in the early stages. Clients are now given homework with an approach to track client’s cognitive ability, and to tailor tasks accordingly. Discussing the client’s experiences and the meaning of psychosis is an important part of CBT. At this stage the clients do not recognize that they have a mental illness or the contribution of a symptom towards their illness; instead they believe they have some kind of personal dysfunction. The therapist at this stage constructs a new model of events that make sense to the client in order to reevaluate client’s belief. The therapist finds out what is the current understanding of psychosis by the client. Here is when the therapist offers an individualized formulation, though tentative. The formulation is based on the broad stress-vulnerability frameworks, but within client’s subjective experience of psychosis. Through these formulations, the therapist tries to make links between client’s life history and the identified vulnerability factor. At this point biopsychosocial theories and mechanism of antipsychotic medications are discussed. The ultimate aim of this stage is to reduce the guilt or denial associated with psychosis and to engage the client in behavior that will increase the functioning of the client and reduce the risk of relapse (Garety, Fowler and Kuipers, 2000). As for the delusions and hallucinations, the therapist tries to assess the content of the beliefs or voices; and if they are mood congruent. It is important that the therapist understands the events around which these delusions and hallucinations started. Are there any modifiers making them less or more intense? Is there any benefit or risk in holding the beliefs or the voices heard? It also helps the therapist to know if the client is using any coping strategies and if it is helping him/her. Finally, the therapist tries to understand the relation between delusions and hallucinations. To treat hallucinations, the therapist addresses the attributes of the voices; in that he asks the client to ignore the commands of the voices and see if the catastrophic predictions truly occurs or not. The aim is to let the client take command over the voices and ignore them. The client is made aware of the fact that the voices originated in his/her thoughts by what is called normalization of hallucinations. Psycho-education at this point also helps the client. From the identified modifiers, the therapist asks the client to implement on the situations or behaviours that either calms the voices or makes them less distressing (Garety, Fowler and Kuipers, 2000). This is the beginning of the coping strategies. For delusions, the therapist tries to reduce the intensity of the beliefs, by weighing upon whether the beliefs are true or false. This should come from the client and not the therapist. Here, the therapist provides the client with evidence which either supports or refutes the beliefs (Whitfiled and Davidson, 2007). Some therapists consider delusions and hallucination as intrusions into awareness that are misinterpreted in certain ways and are viewed as psychotic phenomena. Natures of these misinterpretations depend on experience, beliefs, and knowledge of the client. These psychotic misinterpretations are maintained by safety behaviour, plans for processing faulty self and social knowledge (including metacognition). These misinterpretations cause the associated distress and disability in the clients (Morrison, 2001). Residual symptoms of hallucinations and delusions are seen in depressed people with psychosis. The clients feel hopeless and uncontrollable, which may contribute to the symptom maintenance (Birchwood and Iqbal, 1998). Garety and colleagues say that three processes traditionally associated with anxiety and distress are important, namely, information processing biases, safety-behaviours, and meta-cognitive beliefs (Garety, Fowler and Kuipers, 2000). Clinically, it has also long been observed that anxiety triggers hallucinations and increases in delusional thoughts, i.e. affects cognitive processing (Slade, 1972). To treat low self-esteem, depression and anxiety, the therapist’s standard cognitive approaches of identifying automatic thoughts, dysfunctional assumptions and reappraisal may take the form of assisting the client to view him or herself as someone who has struggled heroically with adversity (Garety, Fowler and Kuipers, 2000) To manage the risks of relapse Birchwood et al have identified several ‘early warning signs’ of relapse referred to as ‘relapse signature’. These signs can be racing thoughts, possession of special powers, thinking that other people can read your mind (and vice versa), having more nightmares, hearing voices etc. The authors feel that environmental stressors act on the vulnerable individuals, therefore a reduction in stress or other acquisition of stress management skill should decrease the chances of psychotic relapse. This can be done using CBT or medications (Birchwood, Spencer and McGrovern, 2000). CBT has its own pros and cons. The pros of CBT are that CBT can be as successful as medication in depression and other mental health disorders. Compared to other talking therapies, CBT can be completed in relatively shorter duration. CBT is available in many forms, including, computers, cell phones, and in groups. Skills learnt in CBT can be applied to day-to-day life to reduce stress. CBT also has its own cons; it can be helpful only if the client shows 100% commitment to the therapy engaging in full range of therapy procedures; partial therapy is not effective in clients with psychosis (Dunn, et al., 2012). Since it is highly structured it may not be helpful to illiterate, clients with more complex mental health, or those who have learning difficulties. CBT expects the client to change his/her thinking, feelings, behavior etc. but has limitations in applying these changes to the people surrounding the client, who can have strong impact on the client’s wellbeing. To conclude, CBT, although effective, comes at a higher cost compared to “treatment as usual” (van der Gaag et al., 2011). Besides, everyone is not suitable for CBT. Age, sex, and intelligence have no effect on the outcome of CBT; but occupation, personality and culture can show different or slower response (Blenkiron, 1999). Some of the larger studies on the efficacy of CBT have shown no significant advantage for CBT over the control intervention. (Lewis, Tarrier, and Haddock, 2002, Sensky, Turkington and Kingdon, 2000, Cormac, Jones, Campbell, 2002). “If CBT were a drug, these studies would have been sufficient to consign it to history” (Turkington and McKenna, 2003). Birchwood and Trower (2006) believe that the currently designed large-scale pragmatic trials for CBT for psychosis will “neither shed further light on the active agents of CBT for psychosis nor initiate a process that will improve the effectiveness or specificity of CBT for psychosis. In fact they run the risk of doing the opposite.” They suggest that the new studies should be theory driven and focus on emotional dysfunction and/or behavioural anomaly as seen in psychosis, with an aim to treat distress and have secondary effect on psychotic phenomena. They believe that the future of development and improvement of CBT for psychosis lies in moving away from the neuroleptic resemblance and understanding the interface between emotions and psychosis. They suggest CBT to be complementary to neuroleptics, but not substitutive. Reference List Beck, A.T., 1997. The past and future of cognitive therapy. J Psychother Pract Res, 6(4), pp 276- 84 Birchwood, M. and Iqbal, Z., 1998. Depression and suicidal thinking in psychosis: a cognitive approach. In Outcome and Innovation in Psychological Treatment of Schizophrenia (ed. T. Wykes, N. Tarrier & S. Lewis), pp. 81-100. Wiley: Chichester. Birchwood, M., Spencer, E., and McGrovern, D., 2000. Schizophrenis: early warning signs. Advances in Psychiatric Treatments, 6, pp 93-101. Birchwood, M. and Trower, P., 2006. The future of cognitive-behavioural therapy for psychosis: not a quasi-neuroleptic. Br J Psychiatry,188, pp 107-8. Blenkiron, P., 1999. Who is suitable for cognitive behavioural therapy? J R Soc Med, 92(5), pp 222-9. Cormac, I., Jones, C. and Campbell, C., 2002. Cognitive behaviour therapy for schizophrenia. Cochrane Database Syst Rev, (1), CD000524. Dunn, et al., 2012. Effective elements of cognitive behaviour therapy for psychosis: results of a novel type of subgroup analysis based on principal stratification. Psychol Med, 42(5), pp 1057-68. Fowler, D. and Morley, S., 1989. The cognitive-behavioural treatment of hallucinations and delusions: A preliminary study. Behavioural Psychotherapy, 17, pp 267-82. Fowler, D., Garety, P. and Kuipers, E., 1995. Cognitive Behaviour Therapy for People With Psychosis. Chichester, England: John Wiley and Sons. Freeman, D., and Garety, P.A., 1999. Worry, worry processes and dimensions of delusions: An exploratory investigation of a role for anxiety processes in the maintenance of delusional distress. Behavioural and Cognitive Psychotherapy, 27, pp 47-62. Garety, et al., 2001. A cognitive model of the positive symptoms of psychosis. Psychol Med, 31(2), pp 189-95. Hemsley, D.R., 1994. The Neuropsychology of Schizophrenia. Hove, England: Lawrence Erlbaum, pp 97-116. Lewis, S., Tarrier,N., Haddock, G., 2002. Randomised controlled trial of cognitive-behavioural therapy in early schizophrenia: acute-phase outcomes. British Journal of Psychiatry, 181(43), pp 91-7. Morrison, A P., 2001. The interpretations of intrusions in psychosis: An integrative cognitive approach to hallucainations and delusions. Behavioural and Cognitive Psychotherapy, 29, pp 257–76). Sensky,T., Turkington, D. and Kingdon, D., 2000. A randomized controlled trial of cognitive behavioural therapy for persistent symptoms in schizophrenia resistant to medication. Archives of General Psychiatry, 57, pp165-72. Slade, P. D., 1972. The effects of systematic desensitization on auditory hallucinations. Behaviour Research and Therapy, 10, pp 85-91. Turkington, D. and McKenna, P.J., 2003. Is cognitive-behavioural therapy a worthwhile treatment for psychosis? Br J Psychiatry. 182, 477-9. van der Gaag, M., Stant, A.D., Wolters, K.J., Buskens, E., and Wiersma, D., 2011. Cognitive- behavioural therapy for persistent and recurrent psychosis in people with schizophrenia-spectrum disorder: cost-effectiveness analysis. Br J Psychiatry, 198(1), pp 59-65. Whitfiled, G. and Davidson, A., 2007. Cognitive Behavioural Therapy Explained. London: Radcliffe Medical Press Ltd. Read More