CBT FOR SCHIZOPHRENIA

PRESENTER : Ismael Michael

FACILITATOR: Isaac Lema
 INTRODUCTION
 National Institute of Clinical Excellence
(NICE) Schizophrenia  (2003) guideline 
(updated Mar 2009)  stated that CBT should 
be offered to  everybody with a schizophrenia 
spectrum diagnosis; particularly  those with 
persistent and distressing  symptoms and a 
history of relapse
Cognitive behavioral techniques

Cognitive behavioral techniques in psychosis were

first used in 1952 by Beck in a patient who was
paranoid about the Federal Bureau of Investigation.
The patient was encouraged to trace the antecedents
of the delusion and behavioral techniques such as
reality testing were used.
The patient was eventually able to recognize that all
his alleged persecutors were normal people going
about their daily business
(Rathod & Phiri, 2010)
 Cognitive behavioral therapy (CBT)
Cognitive behavioral therapy (CBT) is an evidence-
based adjunct to medication in the treatment of
schizophrenia.
The treatment is acceptable to patients.
It is regarded as an essential treatment in clinical
treatment guidelines.
Evidence has developed from case studies,
randomized controlled trials, and meta-analyses
confirming its effectiveness in persistent positive
and negative symptoms of schizophrenia.
 Treatment Goals
Increased understanding of and insight into
psychotic experiences
Improved coping with residual psychotic
symptoms
Reduction in distress associated with auditory
hallucinations
Reduction of degree of conviction and
preoccupation with delusional beliefs.
Maintenance of gains and prevention of relapse
Overall aim of CBT for schizophrenia

Work with Work with

delusions hallucinations
AIM
To
reduce
distress
and disability

Work with
negative symptoms
 General assessment and introduction to
the therapy
The primary aim of the assessment is to gather
information in order to develop a comprehensive
formulation of the patient’s difficulties.
Another aim is to increase quality of life, it is
important to develop an understanding of areas where
the patient is experiencing more or less difficulty.
Understanding the patient’s expectations of therapy is
an important step in building motivation for therapy,
and in building a collaborative relationship
 Symptom specific assessment…1
Assessment of delusions and/or voices
Delusional Beliefs
The aim of the assessment is to develop a functional
assessment and formulation of delusional beliefs –
including a understanding of predisposing,
precipitating and maintaining factors
A visual analogue scale is simply a 10cm line with
0% at one end and 100% at the other end
When discussing delusional beliefs with the patient it
is helpful to use their own language to describe them
Symptom specific assessment…2
Voices
The aim of the assessment is to develop a
functional assessment and formulation of
auditory hallucinations – including an
understanding of predisposing, precipitating
and maintaining factors.
Using the cognitive behavioral model, voices
are understood as Activating Events or
Triggers rather than Beliefs
 Engagement Strategies

One of the common descriptions of cognitive

behavioral interventions for people with psychosis is
the emphasis placed on the importance of
engagement with the patient.
Enhancing existing coping strategies
Elicit range of already used coping strategies from
patient
Discuss each strategy with the patient in detail
Select a few strategies to use more consistently and
make plans for applying them
 Psycho education…1

Firstly it is an opportunity to normalise the

experience of psychotic symptoms (Turkington &
Kingdon, 1996).
Secondly, it also provides an opportunity for the
patient to increase their understanding of their own
symptoms and the context in which they occur.
(Fowler, Garety, & Kuipers, 1995).
Thirdly, it allows the clinician to further assess their
patient’s understanding of their own illness,
Psycho education…2
Include
What is psychosis
Symptoms of psychosis
Stress vulnerability model of psychosis
Vulnerability factors-genetic
-neurodevelopment
-environment
Life stressors
Protective factors
Stress vulnerability model of psychosis

Biologic and Genetic Vulnerability

• Family History of schizophrenia or Psychosis

Environment Factors
• Living circumstances , social stressors
• Trauma

Onset of illness
• Risk of developing Psychotic illness
Risk of Recurrence of symptoms
 Stress vulnerability model
CBT for schizophrenia differs from other
psychosocial interventions because it is based
on the stress vulnerability model developed by
Zubin and Spring
This model emphasizes the interaction between
life events, circumstances, and individual
genetic, physiological, psychological, and social
predispositions that lead to variation in
vulnerability to psychotic breakdown
COGNITIVE BEHAVIOR

THERAPY

FOR HALLUCINATIONS
What leads to diagnosis?

Having a hallucination does not lead to a

diagnosis
The frequency of occurrence, the meaning of
these experiences to the individual and the
extent to which they interfere with
functioning may determine whether or not
someone who experiences hallucinations has
a diagnosis
 Hearing a voice

Sense of threat
and negative
mood leads to
Interpret voice
hyper vigilance
as a threat
for more input
from voices
(listening harder
for them)

Perception of
threat increases
negative mood
Three levels of belief about voices:

• Beliefs about content

• Beliefs about power
• Beliefs about identity
 How to change beliefs about voices:
Beliefs about content
◦ Use steps similar to those used when working with
“automatic thoughts”
Beliefs about power
◦ Help the person develop better coping tools and so
increase personal power in relation to the voices
Beliefs about identity
◦ Explore interpretations, and evidence for
interpretations, that are less distressing
The ABC model
Activating events;
these will be trigger situations; factors that
precipitate the problem (voice, physical
concern)
Belief about the event or symptom; this is the
interpretation being made
Consequences of the problem; i.e. what
emotions, thoughts, actions or physical
feeling occur
The principle steps are…

1. Distinguishing between thoughts and

feelings
2. Making the connection between thoughts
about voices and feelings
3. Verbal challenging of beliefs about voices
4. Behavioral experiments to test beliefs
5. Developing alternative balanced thoughts
COGNITIVE BEHAVIOR
THERAPY

FOR DELUSIONS
Different cognitive models of delusional
beliefs( cognitive biases)

1) Jumping to conclusions:
 People with delusions show a tendency to seek
relatively less information before making a conclusion.
 This has also been described more specifically as a
‘data-gathering’ bias because it appears that while
people with delusions will tend to gather less
information before making a decision, they show no
difficulties in using further information if it is made
available to them (Garety & Freeman, 1999).
Cognitive biases cont…
2)Attribution biases:
People with persecutory delusions show a
general tendency to blame other people
(rather than chance, or themselves) for bad
events happening to them.
This is an exaggeration of the ‘self serving
bias’ which most people show to a slight
extent (Bentall, 1996).
 Cognitive biases cont…
3) Deficits in ‘theory of mind’:
This refers to difficulties in understanding the
thoughts, intentions and motivations of others.
(Garety & Freeman, 1999)
4) Psychotic patients may also demonstrate the types
of unhelpful thinking styles, for example, their
delusional beliefs may reflect the operation of
catastrophic misinterpretation of bodily sensations,
selective attention to threatening information, or an
‘all-or-nothing style’.
 Three ways of working with delusions:

1. Explore the developmental background out of

which the delusion developed, in other words, work
on the formulation.
2. Explore the delusion itself by
exploring the evidence for and against it
testing out beliefs
3. Help the person expand engagement with the world
and with other people, which reduces preoccupation
with the delusion
Challenging the Delusion Itself
1) Focus on the inconsistency and irrationality of the belief
the belief
“Would it make sense for things to be this way?”
Point out inconsistencies or problems in reasoning
Bizarre delusions are especially vulnerable
2) Belief is an attempt to explain unusual, puzzling, or
ambiguous events puzzling, or ambiguous events
Normalizes the belief
Anxiety is a common pre cursor
3) Discuss emotional and behavioral costs of the delusions
vs. alternative belief
Challenging the Evidence

The first few sessions are devoted to

understanding how the delusion was formed
or important events in the client’s life
Rank order the evidence from least
important to most important
Challenge the least important evidence first
Behavioral Experiments
Behavioral experiments are ways to test out the
clients belief
Experiments Sample Experiments
Client believes she can tell the future
Test: Pause a videotape and ask client what
will occur
Client believes he is an professional football
star–
Test: Access list of players on website to check
The principle steps are…

1. Distinguishing between thoughts and

feelings
2. Making the connection between thoughts and
feelings
3. Identifying the significant delusional beliefs
4. Verbal challenging of delusional beliefs
5. Behavioral experiments to test beliefs
6. Developing alternative coping self-
statements
Behavioral Skills Training…1

The behavioral skills training offers the

clinician (and the patient) a choice from a
range of effective behavioral strategies –
depending on the nature of the patients
presenting concern.
The strategies include – relaxation, graded
exposure, activity scheduling, distraction and
problem solving
Behavioral Skills training…2

1. Problem Solving
 There is evidence that problem solving training may be a
useful core strategy in controlling the life stress
experienced by people with psychosis, which is often
implicated as a factor in vulnerability to relapse
(Falloon, 2000)
 Identify and define problem area
 Generate potential solution
 Eliminate alternatives
 Decide on a solution
 Evaluate the outcome
Behavioral Skills training…3
2. Calming Technique
Physical arousal, or tension and the emotional
state of anxiety have been implicated in the
establishment and maintenance of positive
psychotic symptoms. It follows then that teaching
a skill for managing anxiety and arousal states
will be particularly helpful for those with
persistent psychotic symptoms.
Controlled breathing
Relaxation via letting go
Behavioral Skills training…4
3. Activity Scheduling
This technique is particularly helpful if you
notice that a patient has a lack of pleasant
and rewarding activity in their daily routine
 Behavioral Skills training…5
4.Behavioural Hierarchies: Graded Exposure/
Graded Task Assignment
 Take a task or goal that the patient wants to
achieve
Break it into a series of more manageable tasks
Make sure each task is specific and realistic
Plan with the patient to gradually work through
the series of tasks to achieve the overall goal.
Coping strategies…1
Ways of coping (Gamble &Brennan, 2007)

Interacting
Distraction Voices;
Voices and strange ,worrying Telling the voices to go away
thoughts; Talking to the voices while
Listening to music pretending to use a mobile
Reading aloud phone
Counting backwards from 100 Agreeing to listen to the
Describing an object in detail voices at particular times
Watching TV Strange, worrying thoughts;
Testing out beliefs
Coping strategies cont…2
Activity
Voices and strange, Social
worrying thoughts; Voices and strange,
Walking worrying thoughts;
Tidying the house Talking to a trusted friend
Having a relaxing bath or member of the family
Playing the guitar Phoning a helpline
Singing Avoiding people
Going to the gym Visiting a favourite place
Normalizing:
Interpreting psychotic experiences as an
understandable reaction to events or
combinations of events
◦ This reduces the panic and emotional arousal that
often leads to more symptoms
◦ Normalizing means looking at experiences as
existing on a continuum, not divided into
categories such as sane and insane
Self management planning
1. Early warning signs
Monitor early warning signs
2. Self-management planning
Make a plan about what to do when these early
warning signs are identified.
3. Maintaining changes and staying well
The ‘Self - Management Plan’ also offers an
opportunity to reflect on the broader range of
things that the patient can do to maintain
psychological wellness in the long term.
Relapse prevention
Relapse prevention strategies usually
include identification of early warning signs
for relapse, and development of plans for
acting in response to these indicators. They
have been used in combination with both
pharmacological and psychological
treatment regimes, over many years
(Birchwood,
 REFERENCE
Smith, L., Nathan, P., Juniper, U., Kingsep, P., &
Lim, L. (2003) Cognitive Behavioural Therapy
for Psychotic Symptoms: A Therapist’s Manual.
Perth, Australia: Centre for Clinical Interventions.
Rathod, S., & Phiri, P. (2010). Cognitive
Behavioral Therapy for S c h i z o p h ren i a, 33,
527–536. http://doi.org/10.1016/j.psc.2010.04.009
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