Psychosis: Counseling the Hallucinating or Delusional Patient

1. Psychosis:Counseling the Hallucinating orDelusional Patient Presented by Ron Broughton, M.Ed., L.P.C. Chief Clinical Officer Brookhaven Hospital Tulsa, Oklahoma

2. Objectives • Overview of medications & efficacy • Historical examination of the role of psychotherapy with psychotic patients • Review recent research of CT/CBT • Learn specific therapy strategies for psychosis • Overview the of ABC model

3. Definitions • Delusion: a false belief based on an incorrect inference about external reality that is firmly sustained despite what almost everyone else believes, and despite what constitutes incontrovertible and obvious proof or evidence to the contrary. • Hallucination: a sensory perception that has the compelling sense of reality of a true perception but that occurs without external stimulation of the relevant sensory organ • Is it inside or outside? Interestingly, the DSM-IV “makes no distinction as to whether the source of the voices is perceived as being inside or outside of the head.”

4. Charlie Brown’s View

5. Atypical Medications

6. Medication & Efficacy

7. Research on Psychotherapy and PsychosisThree Recent Eras

8. Medication vs. Therapy Medication Superior Focus On Problem Solving Experienced Therapists Better Outcomes* Psychotherapy 1960-1975

9. Psychotherapy 1980-1995

10. The Early Theme • Psychodynamic approaches not effective • Strong therapeutic rapport • Personal therapy more effective • Experienced clinician + individualized approach = better outcome

11. An Evolution Begins Creativity is a drug I cannot live without. --Cecil B. De Mille

12. Evolvement in the Late 90’s

13. The Late 90’s Results Compared to supportive & psychoeducational treatment

14. The New Statistics Don’t Forget Your Favorite College Course

15. Recent ResearchSivec, H.J. & Montesano, V.L., 2012 • Effect size: .20 small .50 medium .80 large • Meta analyses indicate CBT .35-.40 • Three months follow-up .06-.40 • One year follow-up .32 • Majority of reviews favorable • CBT-P recommended in Europe and U.S.

16. CBT Research & Hallucinations Reduces & decreases severity

17. CBT Research & Hallucinations Increases quality of life

18. CBT Research & Hallucinations CBT Coping Skills Medication Family Therapy Integrative Approach

19. CBT Research & Hallucinations Overall, CBT IMPACTS Hallucinations

20. CBT Research & Delusions Studies Have Mixed Results

21. CBT Research & Delusions • Some no effect until follow-up • Early decrease, not @ follow-up • Others: • 1/3 with decrease in conviction, preoccupation & anxiety • 1/3 No change • 1/3 In between

22. Client Satisfaction • Was treatment positive/helpful? • CBT = 70% “Yes, definitely” • ST = 37% • TAU = 30% Reason unclear, perhaps the therapeutic relationship?

23. Strategies

24. Strategies Establish a strong therapeutic rapport

25. Strategies Stress reduction Relaxation techniques to stabilize Systematic desensitization to stabilize 5,4,3,2,1 to stabilize Normalize the experience DoNot use “delusion, hallucination, psychosis” Know the belief well

26. Strategies Verbal challenge—the evidence Voice logs Client write out delusional content Evidence logs Change topic if client agitated Relapse prevention plan

27. Therapist Role—Some Tips • Avoid waiting for the “meds to kick in” • Be reliable, predictable & dependable • Simple, honest accurate communication • Have a healthy curiosity—reflection & restatement of content • Walk in the delusion, don’t collude with it • Restrict use of silence, or watch the eyes • If agitated, go to a neutral topic

28. The ABC Model for PsychosisThe Philosophy Noumenon An object as it is in itself, independent of the mind.

29. The Philosophy Our reality is interpreted through our senses & beliefs, The “B” of the ABC Model

30. Delusions on a Continuum Less Normal More All of us fall on the continuum.

31. 5 Principles of the ABC Model • All clinical problems are C’s. • Problems arise from B’s not A’s. • There are predictable connections between B’s and C’s. • Core B’s arise from early experiences. • Weakening beliefs weakens associated distress & disturbance.

32. Eight Basic Steps • Client defines a problem • Assess A or C • Assess the one that remains • Connect A to C & determine that is the clients primary worry • Assess beliefs, inferences & evaluations

33. Eight Basic Steps • Formulation: • Show the B-C connection • Offer a developmental formulation • Set client’s goals & consider his options • Avoid or escape • Do nothing • They can change them in some way • Reduce by changing core beliefs

34. Eight Basic Steps • Challenge beliefs • Disputing and testing inferences • Disputing and testing evaluations Note: this is sequence of conceptual steps, not of technical ones. Lengthy & dynamic process.

35. Case Study #1 • Delusional set • Excessive religiosity • Minimal ADL’s • Reading the Bible and prayer only • Interventions • Assessed A’s • Assessed C’s • Assessed B’s (inferences, evaluation & interpretation) • Challenged B’s • Family therapy

36. Case Study #2 • Indeterminate delusional set • Highly intelligent • Mathematics wiz • “Word salad” • Interventions • Assessed A’s • Assessed C’s • Unable to assess B’s • Focused on health & safety

37. Review • Brief overview of medications & efficacy • Historical examination of the role of psychotherapy with psychotic patients • Review recent research of CT/CBT for psychosis • Learn specific therapy strategies for psychosis • Overview the ABC model

38. Some Conclusions • Therapeutic work lengthy • Rapport is essential • Requires patience and empathy • DO NOT try to convince client • Use Socratic dialogue—client draws on his own experience & doubt • ABC model and schema therapy

39. Questions? Thank You!