assessment life history, critical incidents, current environment, congruence with symptoms...

Assessment

• Life history, critical incidents, current environment, congruence with symptoms

• Standardised measures– PSYRATS– BAVQ, IVI, BAPQ– Mood, Safety behaviour interview, TCQ etc.– PTCI, DES, CTQ, THQ

• SMART goals, belief ratings etc.

Formulation

4 levels:• basic / horizontal• maintenance• internal generation• historical / developmental / vertical

Basic Formulation

EVENT THOUGHT FEELING BEHAVIOUR

hear voice it’s the devil scared pray & visit church

see ceefax I’m the devil scared burn self

p666

Maintenance Formulation

Triggers (cannabis, paranoid thoughts, arousal, religious )

Hear Voices

scared, increased arousal pray, hide in church,

no sleep attend to relevant stimuli

It is the devil trying to possess make me harm people

Historical FormulationEarly Experiences

mental and sexual abuse from religious motherphysical abuse from father to both

told to harm father; told she was evilcatholicism

Beliefs FormedI am evil and the devil is in me

I might harm other peopleMust think good thoughts

Thinking something evil is as bad as doing it

Critical IncidentRaped

Hear voices saying bad things

ExperienceBullying Physical AbuseEmotional abuse

Cog. & Beh. responsesSafety behavioursDissociationThought supressionAvoid situationsRun awayLook out for dangerDon’t express self

Mood & physiologyAnxiousHyperarousalParanoidDepressedSleep problems

Making sense of things They are talking about me / want

to hurt meI’m mad / not normal

It’s a Bully from beyond the grave

Intrusions / event Social situations / reminders

Flashbacks / dissociationCritical voices

Beliefs / strategies / rulesI am vulnerable / uselessI am mad / not normalPeople will hurt you & can’t be trusted‘Paranoia’ keeps me safeBullying was my faultIf I keep busy or spaced out then I won’t have time to think / feel bad

Experiences that worry meHear whispering and laughingSee bodiesSee people staring

What I make of itThey might be ghostsI must be going madThey might harm me

What I make of the self / worldI should be in total controlI am badNeed to be alert for dangerOther people cannot be trusted

Early experiencesBaby brother died, mum blamed meSexually abused aged 14Dad horrible to me

What I doTry to stay in control of thoughts Hide from ghostsLook out for things happening to me

How I feelscaredagitatedangrysad

Formulation Exercise

• Role play assessment of patient and formulation

Video

• Developing case formulation

Exercise

• Suggest intervention strategies based on formulation

Normalising psychotic experiences

• Trauma (assault, bullying, kidnap, combat)• Drug abuse• Isolation / Sensory deprivation• Bereavement• Sleep deprivation

http://www.amazon.co.uk/gp/product/images/158391837X/sr=8-2/qid=1240502329/ref=dp_image_0?ie=UTF8&n=266239&s=books&qid=1240502329&sr=8-2

Some well known voice hearers:

• Philosophers and thinkers: Socrates Plato Aristotle Descartes Mahatma Gandhi

• Authors, musicians and creative artists: Jonathan Swift Beethoven Mozart Byron Edgar Allen Poe Charles Dickens Philip K Dick Anthony Hopkins Zoe Wanamaker Paul McCartney Brian Wilson

Spiritual and religious figures: Moses Jesus Mohammed Joan d'Arc George Fox (Founder of the Quakers)

Leaders and rulers Alexander the Great Caesar Oliver Cromwell Napoleon Churchill

Scientists,Discoverers & Explorers Christopher Columbus Galileo Isaac Newton John Nash

FootballersTony CascarinoPaul Gascoigne

• “I’ve learnt a lot...erm I guess about mental health it happens to a lot of people and things like... I thought I was abnormal, especially when I was down I thought what is wrong with me erm and [therapist] would always say well would you think somebody was normal if they had green eyes, and you’d be like yeah, and she’d say like... well more people have mental health problems than have green eyes” (8)

• “…all these thoughts, I was thinking when I felt fine, oh my god they’re crazy but [therapist] helped me to see that the thoughts weren’t crazy, after looking at what happened” (1)

Common Treatment Strategies• Advantages and disadvantages• Normalisation and formulation• Evidence for and against• Explore meaning / downward arrows• Modify environment• Belief restructuring:

– Historical review– Meaning of event– Continuum– Evidence, data log

• List alternative explanations – Conviction ratings– Pie chart– Refer to feelings and behaviour

Common Treatment Strategies• Behavioural experiments:

– Drop safety behaviours– Exaggerate and drop– Attentional focus– Test reality– Practical stuff– Test alternatives– Monitoring– Symptom induction– Surveys

• Metacognitive – beliefs (e.g. positive/negative beliefs about

paranoia/rumination/worry)– strategies (e.g. postponing perseverative processing)– attentional strategies (e.g. external focus)

• “We could test out our predictions, and like look for other explanations like, there was some exercises in the CBT that I could do...so eventually I’d feel, like I’d get a de-escalating feeling of anxiety” (1)

• “I think the evidence thing’s kind of good, sort of it is real and you have to sort of work out well, is it likely to be real. Like if you think, say, people taking thoughts out of my head, and erm, it’s sort of well what’s the proof that they are” (2)

Intervention: Delusions

• Identify thoughts, feelings & behaviour• Evaluate advantages and disadvantages• Evaluate thoughts:

– evidence for and against– generate alternative explanations– advantages & disadvantages

• Education– anxiety, intrusions, metacognition,– reasoning biases, thinking errors, selective attention

• Behavioural experiments

Advantages Disadvantages

Makes me feel special

Keeps my belief in a soulmate

Makes life feel special

Frustration when Richard and I do not meet.

Causes difficulties with present partner

Has got me into trouble with the police in the past

My psychiatrist thinks this is a problem

It upsets my daughter a lot

I’m distraught when Richard tells me he is not in love with me

Anger towards Richards wife

Unable to go away for the weekend as need to stay near house in case Richard decides to come and see me

Evidence for“The neighbours are going to attack

me”

Evidence against“The neighbours are going to attack

me”

There are rowdy noises from next door I have been assaulted by other people in the past They can read my mind

I have seen them 3 times this week and they haven’t attacked me I have never been assaulted by anyone from my street I have never seen the neighbours be violent to anyone I don’t think they are going to attack me when I am drunk or when I am with other people

Evaluating interpretationsThe rowdy noises from next door are due to:

Initial belief: The neighbours want to attack me 80%

The neighbours are having a party 25%

The neighbours are having an argument 50%

The neighbours are making noises to wind me up 50%

I am imagining the noises 10%

The noises are being beamed into the house from outer space 0%

Stress, lack of sleep & beliefs are making me misinterpret noises 25%

Interpretations of Voices

• mediate distress• identify

• use modified DTR• use questionnaires• use interviewing• use downward arrows to access personal meaning• use content• use qualities of voice


• evaluate by• use of list of interpretations• generate alternative interpretations• relate to normalising information• rate & rerate belief each session• use diaries / monitoring

» include how related were the voices to your thoughts or worries or yourself


• Evaluating...• examine evidence for and against

» including content» use shadowing» compatibility of modulators

• behavioural experiments» drop/modify safety behaviours» manipulate attentional biases» control


• encourage one to be internally generated• provide information re: research• behavioural experiments using subvocalisation• analysis of voice content in relation to thoughts• education re: intrusive thoughts• identify metacognitive beliefs• challenge metacognitive beliefs

Content of Voices

• Can mediate distress• Identify using:

– modified DTR– shadowing– role play– diaries

Content of Voices

• Challenge using:– link between thoughts and voices– evidence for and against– alternative explanations– role play– flashcards

Content of Voices & Schema

• Content of voices often related to experience

• bullying• sexual abuse / rape• worthlessness• evil• guilty• threat

Content of Voices & Schema

• Challenge using Padesky’s (1994) techniques:– continuum methods– surveys– historical test– positive data logs

Why homework?

The rationale for homework• The idea that homework enhances therapy

should be replaced by the idea that therapy enhances homework.

Secondary gains of homework• active • achievement• collaborative nature of the therapeutic

relationship • empowerment

6 golden rules for maximising homework compliance

• Decide work to be done jointly. • Clearly identify the rationale for doing the

homework. • Check out obstacles. • Make the homework meaningful but

achievable. • Establish prompts. • Begin the use of homework from the first

session.

• “I feel if I hadn’t done the homework that I had, then, and showed up to the sessions as well, I think it would have taken me a lot longer” (1)

• “…when I first like you know got told I was gonna have CBT you just expect you get better but it doesn’t, there’s a lot of like, you got a put a lot in yourself to get a lot out really” (7)

• “So once we had worked out that I was actually doing it right I could do it by myself” (1)

Behavioural experiments

• A powerful way to test alternative belief derived from verbal testing

• Facilitates ‘gut’ level change• Links behaviour with personal meaning• Specifically targeted - increases efficiency

and effect• Wider range of uses

Behavioural experiments

• Can include:– Observations– Surveys– Acting ‘as if’– Hypothesis testing (A/B)– Increasing / Decreasing responses – Symptom induction– Role plays

Issues of design

• Be collaborative• Motivation to complete them• Practical implementation

‘People can hear my thoughts’

• Behavioural experiments– Drop safety behaviours– Suppression vs. counter-suppression– Recording– Deliberate broadcasting to provoke responses– Surveys

Principles of Cognitive Therapy· A cognitive model is required from which to empirically derive

effective treatments:FORMULATE USING MODEL

• What are you concerned about?SHARE A GOAL

• You are not mad, you are normal: NORMALISE

• Either it is real or you believe it to be real: SIT ON A COLLABORATIVE FENCE

• How you appraise events contributes to distress: EVALUATE USING E-T-F-B

• It’s not always what you think, sometimes it’s how you thinkMODIFY CONTROL STRATEGIES

• Test it out – drop your safety behaviours: EXPERIMENT IN & OUT OF

SESSION

Tips

• Important to relate to goals (usually emotional change or changing ‘what I do’ to improve QoL)

• Use match between appraisal and emotion, and emotion and behaviour

• Only draw in arrows with agreement – otherwise investigate relationships

• Normalise the ‘story’• Use arrows to plan treatment

Tips

• Agree a shared goal first and foremost• Explicit structure and labels• Focus on specifics, not general• Leave plenty of time for ‘between session

tasks’

CBT for psychosis

• NICE guidelines say at least 16 sessions over at least 9 months

• Numerous meta-analyses in support (BUT as adjunct to antipsychotics in most participants)

• Aims to reduce distress and improve quality of life

Inclusion criteria

• 1) either meet ICD-10 criteria for schizophrenia, schizoaffective disorder or delusional disorder or meet entry criteria for an Early Intervention for Psychosis service (operationally defined using PANSS) in order to allow for diagnostic uncertainty in early phases of psychosis

• 2) either have at least 6 months without antipsychotic medication and experiencing continuing symptoms OR never have received antipsychotics and be currently refusing

• 3) score at least 4 on PANSS delusions or hallucinations or at least 5 on suspiciousness/persecution, conceptual disorganisation or grandiosity

Measures• Symptoms:

– PANSS– Psychotic Symptom Rating Scales

(PSYRATS; Haddock, McCarron, Tarrier and Faragher, 1999).

• Recovery– A user-defined measure of recovery (QPR;

Neil et al., 2009)• Functioning

– PSP

CONSORT diagramReferred (n = 43)Assessed for eligibility (n= 26)

Enrollment

Excluded (n= 6)

Not meeting inclusion criteria(n= 5)

Refused to participate(n= 1)

Allocated to intervention(n= 20)

Received allocated intervention(n= 19, 1 withdrew after 1 session)Allocation

Follow-Up

Assessed n =17 declined n = 1 withdrew n = 2

Analysis

Analysed (n= 20)Excluded from analysis

(n=0)Last observation carried

forward (LOCF) at end of treatment analysis (n = 3)

LOCF at follow up analysis (n = 5)

Patient characteristics

• Gender– Male N = 10– Female N = 10

• Age– Mean = 26– Range 16 - 56

• Ethnicity– White British N = 16– Black African N = 1– Black Caribbean N = 1– Other N = 2

Diagnosis

• Schizophrenia N = 15• Schizoaffective Disorder N = 4• Delusional Disorder N = 1• Disabling hallucinations N = 13• Disabling delusions N = 17• Both delusions and hallucinations N = 10

CT

• 8 therapists contributed to the delivery of CT within the trial.

• The number of participants treated by each ranged between 1 and 10.

• participants received a mean of 16.7 sessions (S.D. = 7.26; range 1 to 26)

• Acceptability: no participant not attending any sessions, and 19/20 receiving 6 or more sessions

Effect size analyses (Cohen’s d)

Variable Baseline to end of treatment

Baseline to 6 month follow up

PANSS positive 0.87 1.05

PANSS negative 1.00 0.77

PANSS general 0.51 1.06

PANSS total 0.85 1.23

PSYRATS delusions 0.98 0.99

PSYRATS voices 0.56 0.79

PSYRATS total 0.90 1.07

PANSS total – mean scores at baseline, end of treatment and follow up

A significant difference from baseline to end of treatment was identified (p = 0.001)

A significant difference from baseline to follow up was identified (p = .0001)

39.55

29.05

21.88

0

5

10

15

20

25

30

35

40

45

baseline (SD=11.9) end of treatment(SD=19.1)

6 month follow up(SD=17.1)

Secondary outcomesPANSS positive – mean scores at baseline,

end of treatment and follow up



11.75

7.65

5.94

0

2

4

6

8

10

12

14

baseline (SD = 4.74) end of treatment (SD =7.37)

6 month follow up (SD =5.99)

Secondary outcomesPSYRATS delusions – mean scores at baseline,

end of treatment and follow up



14.7

6.455.23

0

2

4

6

8

10

12

14

16

baseline (SD=6.66) end of treatment(SD=7.07)

6 month follow up(SD=6.3)

Secondary outcomesPSYRATS voices – mean scores at baseline, end

of treatment and follow up



19.35

10.819.48

0

5

10

15

20

25

baseline (SD=15.02) end of treatment (13.55) 6 month follow up(12.34)

Secondary outcomesVariable Pre

treatment:Mean (SD)

Post Treatment:Mean (SD)

Follow up:

Mean (SD)

Pre- treatment to post-treatment

Pre-treatment to follow-up

t p d 95% CI t p d 95% CI

QPR total 48.83 (15.69)

57.22 (18.59) 60.96 (18.80)

-1.69 .110 .41 0.09,0.90

-2.50 .024 0.65 0.08,1.11

PSP total 47.4 (13.80)

56.45 (18.37) 66.05 (18.31)

-2.44 .025 0.54 0.07,1.01

-3.99 .001 0.87 0.34,1.37

Good and poor clinical outcomes.

25%+ Decrease on PANSS = Good clinical outcome

25% +Increase on PANSS = Poor clinical outcome

Total N 0 – 24% increase

0% - 24% reduction

25% - 49%Reduction

50% - 74% reduction

75% - 100% reduction

End of therapy

20 3 7 3 5 2

6 month follow up

20 2 7 1 6 4

Table 2. % decrease on PANSS total scores at end of therapy and follow up

Secondary outcomes: initiation of antipsychotic medication

0

3

17

0

2

4

6

8

10

12

14

16

18

Started on antipsychotic medication

during therapy

Started on antipsychotic medication

post therapy

Not started on antipsychotic medication

Predictors at 9 monthsPANSS total change

PSYRATS delusions change

PSYRATS voices change

BAPS: negative change .465* .426 -.078

IVI: metaphysical change

-.187 .038 .277

IVI: control change .255 .388 .707**

Age .443 -.295 -.529*

DI -.774** -.817** -.017

DUP -.307 -.476 .127

Number of sessions -.096 -.026 -.083

Gender .000 -.018 -.152

Predictors at 15 monthsPANSS total change

PSYRATS delusions change

PSYRATS voices change

BAPS: negative change .647** .468* -.280

IVI: metaphysical change

-.314 -.096 .318

IVI: control change .088 .260 .470*

Age -.318 -.348 -.385

DI -751** -717** .036

DUP -.377 -.368 .089

Number of sessions 0.22 .002 -.007

Gender -.038 -.024 -.149

Limitations

• Pilot study– Small (N = 20)– No control group– No randomisation– Rater bias?– LOCF (but only one condition)

ACTION: Assessing Cognitive Therapy Instead Of Neuroleptics

• Two site single blind RCT with two conditions (CT plus TAU vs. TAU) for people with psychosis not taking antipsychotic medication (due to refusal or discontinuation)

• Assessments are 3 monthly following the initial baseline assessment (i.e. at baseline, 3, 6, and 9 months)

• Follow-up assessments are at 12, 15 and 18 months

• n=74

Baseline PANSS data

PANSS subscale Mean(S.D)

PANSS positive total 20.89(4.91)

PANSS negative total 14.31(4.61)

PANSS general total 36.18(7.70)

PANSS total 71.55(13.76)

Reasons for not taking antipsychotics

Antipsychotic naïve: discontinued ratio 34:40

Reasons for not taking anti-psychotic medication

Side effects 23 (31.08)

Philosophical view on psychosis – disagrees with the medical model/ preference for psychological treatment

15 (20.27)

Health reasons including pregnancy 5 (6.76)

Symptoms are unresponsive to anti-psychotic medication

4 (5.41)

Disagrees with diagnosis 6 (8.11)

Other 16 (21.62)

Data unable to be captured 5 (6.76)

• Treatment options for first episode psychosis – If the child or young person and their parents or

carers wish to try psychological interventions (family intervention with individual CBT) alone without antipsychotic medication, advise that psychological interventions are more effective when delivered in conjunction with antipsychotic medication. If the child or young person and their parents or carers still wish to try psychological interventions alone, then offer family intervention with individual CBT. Agree a time limit(1 month or less) for reviewing treatment options, including introducing antipsychotic medication. Continue to monitor symptoms, level of distress, impairment and level of functioning, including educational engagement and achievement, regularly.

1.3.27 CBT should be delivered on a one-to-one basis over at least 16 planned sessions (although longer may be required) and:

follow a treatment manual* so that - children and young people can establish links between their thoughts,

feelings or actions and their current or past symptoms, and/or functioning

- the re-evaluation of the child or young person’s perceptions, beliefs or reasoning relates to the target symptoms

also include at least one of the following components: - normalising, leading to understanding and acceptability of their

experience - children and young people monitoring their own thoughts, feelings or

behaviours with respect to their symptoms or recurrence of symptoms - promoting alternative ways of coping with the target symptom - reducing distress - improving functioning.

Case study

• 1-8– Problems and goals (confidence, self-esteem,

low mood and self-harm, voices, low motivation)

– Formulation– Continuum for low self-esteem– Evidential analysis of self-critical thoughts– Positive imagery– Survey / results (judged, relationship, employ)

Experiences that worry meSocial situationsVoices

What I make of itI am not good enoughI must harm myselfVoices are bulliesOthers will harm me

What I make of the self / worldI am differentI am unimportant and worthlessNeed to be alert for dangerOther people cannot be trustedOthers will leave and reject me

Early experiencesFamily criticismNever fit inSevere bullying at school and workWrongful arrest and harassment

What I doTry to stay in control of thoughts Isolate self and withdrawNegative comparisonsRitualsDaydreaming / dissociation

How I feelLow moodHopelessAnxiety Anger

Case study

• 9-11– Revisit goals– Negative comparisons– I’m a failure– Activity for mood

• 12-15– Daydreaming and dissociation (normalising;

pros/cons; diary; modified GAD model)– Voices

Case study

• 16-18– PTSD (grounding, attentional focus,

reconsider meaning)• 19-22

– Social anxiety (stop post-mortems, anticipation > event, stop safety behaviours, external focus, update image)

triggerSocial situations

Negative thoughtOthers will judge meOthers will reject me

Image of selfWeakVulnerableHunchedUglyVery skinnyUnconfidentShaky

What I doArrive lateAvoid eye contactOnly speak to people I knowSpeak with hand over mouthDoodle/fidgetHunch up and try to disappear

How I feelAnxiety TensePalpitationsSweatyShaky

Case study

• Progress:– I am good enough 0% 80%– Social confidence 10% 70%– I am different 100% 50% (neutral)– I’m as important as others 0% 80%– No flashbacks, no self-harm, no suicidal thoughts– Voices only at night and managable– Getting married– Doing postgraduate course

Does CBT work for transition?12 month outcomes

Study or Subgroup

ADDINGTON2011AMORRISON2004MORRISON2011PHILLIPS2009VAN DER GAAG2012

Total (95% CI)

Total eventsHeterogeneity: Tau² = 0.00; Chi² = 2.77, df = 4 (P = 0.60); I² = 0%Test for overall effect: Z = 2.57 (P = 0.01)

Events

02779

25

Total

1626952975

241

Events

35

106

20

44

Total

1516931986

229

Weight

2.5%9.0%

24.4%24.3%39.7%

100.0%

M-H, Random, 95% CI

0.13 [0.01, 2.40]0.25 [0.05, 1.12]0.69 [0.27, 1.72]0.76 [0.30, 1.93]0.52 [0.25, 1.06]

0.55 [0.35, 0.87]

CBT SC Risk Ratio Risk RatioM-H, Random, 95% CI

0.5 0.7 1 1.5 2Favours CBT Favours SC

Does CBT+AP work for transition?

Study or Subgroup

MCGORRY2002PHILLIPS2009

Total (95% CI)

Total eventsHeterogeneity: Tau² = 0.02; Chi² = 1.13, df = 1 (P = 0.29); I² = 11%Test for overall effect: Z = 1.73 (P = 0.08)

Events

67

13

Total

2427

51

Events

106

16

Total

1719

36

Weight

56.2%43.8%

100.0%

M-H, Random, 95% CI

0.42 [0.19, 0.94]0.82 [0.33, 2.06]

0.57 [0.30, 1.08]

CBT + risperidone SC Risk Ratio Risk RatioM-H, Random, 95% CI

0.5 0.7 1 1.5 2Favours CBT + risperidone Favours SC

Does CBT work for symptoms in UHR?

Study or Subgroup

PHILLIPS2009ADDINGTON2011AMORRISON2004MORRISON2011

Total (95% CI)

Heterogeneity: Tau² = 0.00; Chi² = 0.94, df = 3 (P = 0.82); I² = 0%Test for overall effect: Z = 2.48 (P = 0.01)

Mean

2.85.2

10.541714.88

SD

2.95.6

3.0500115.54

Total

27273595

184

Mean

3.16.6

10.928620.84

SD

34.7

2.9990817.75

Total

18242393

158

Weight

12.9%15.1%16.6%55.4%

100.0%

IV, Random, 95% CI

-0.10 [-0.70, 0.50]-0.27 [-0.82, 0.29]-0.13 [-0.65, 0.40]-0.36 [-0.64, -0.07]

-0.27 [-0.49, -0.06]

CBT SC Std. Mean Difference Std. Mean DifferenceIV, Random, 95% CI

-1 -0.5 0 0.5 1Favours CBT Favours SC

What do service-users want?

0

10

20

30

40

50

60

PACE EDIE PRIME EDIE-2

% o

f dr

opou

ts

McGorry et al. 2002

[CBT plus risperidone]

McGlashan et al. 2006

[Olanzapine]

Morrison et al. 2004

[CT]

Morrison et al. 2012

[CT]

NICE draft guideline: Psychosis and schizophrenia in children and

young people: recognition and management

• Treatment options for symptoms not sufficient for a diagnosis of psychosis or schizophrenia

• When transient or attenuated psychotic symptoms or other mental state changes are not sufficient for a diagnosis of psychosis or schizophrenia, consider: – treatments recommended in NICE guidance for any recognised

conditions such as anxiety, depression, emerging personality disorder or substance misuse, or

– individual or family cognitive behavioural therapy (CBT) to decrease distress (delivered as set out in recommendation 1.3.27). [1.2.5]

• Do not offer antipsychotic medication for psychotic symptoms or mental state changes that are not sufficient for a diagnosis of psychosis or schizophrenia, or with the aim of decreasing the risk of psychosis. [1.2.6]

EDIE-2 vs ACTION: StigmaARMS

Mean (SD)Psychosis

Mean (SD)t P 95% CI

Self as abnormal 13.56 (2.53) 13.56 (3.33) -.001 .999 -.760 - .759

Expectations 10.43 (2.70) 10.95 (2.64) -1.531 .127 -1.20 - .150

Shame 5.69 (1.36) 5.88 (1.42) -.979 .328 -.562 - .189

Depression 9.73 (4.48) 9.61 (4.73) .187 .851 -1.09 - 1.32

Social anxiety 41.18 (16.98)

40.77 (18.03) .172 .864 -4.33 - 5.16

EDIE-2 vs ACTION: Stigma

BDI SIAS

ARMS Psychosis ARMS Psychosis

Self as abnormal .471** .375** .405** .376**

Expectations .452** .543** .422** .426**

Shame .332** .486** .325** .442**

Stigma

0

5

10

15

20

25

30

baseline 6 12 24

PBEQ

sco

re

CT

Monitoring

• “I never expected it to be a wondercure, and that Edie 2 at the end of it I was going to feel normal again, but in terms of looking at the horrible side of mental health, I feel as though they’ve confirmed that I’m not going down that road, and that’s helped me feel better inside I guess” (m2)

Summary• Minimise harm from medication, especially if

no benefits• Promote choice and alternatives• Normalise / understand psychosis from a

psychosocial perspective• Reduce distress with CBT• Promote recovery• Promising for preventing first episodes of

psychosis and reducing symptoms in UHR• Work in genuine partnership with young

people

Conclusions

• More research required– Who benefits from antipsychotics– Who benefits from CBT– Alternatives evaluated in comparison to

antipsychotics– Other alternatives

• Reasons for optimism– CBT reduces transition and symptoms in ARMS– CBT is encouraging as an alternative to

antipsychotics for established psychosis– CBT without antipsychotics seems to work well for

early phases of psychosis / young people

• “I feel if I hadn’t done the homework that I had, then, and showed up to the sessions as well, I think it would have taken me a lot longer” (1)

• “…when I first like you know got told I was gonna have CBT you just expect you get better but it doesn’t, there’s a lot of like, you got a put a lot in yourself to get a lot out really” (7)

• “I think what I struggled with was the fact that I was having to look at myself and em, and then there was like homework that came with it you know, and I struggled with that for a while purely and simply because I was having to look at myself” (t8)

• “To be honest there would have been times where there was no way I would have engaged with it or benefited from it…think you’ve got to be ready and motivated for it cos there is quite a lot of thinking and you need to be fairly open minded.” (3)

assessment life history, critical incidents, current environment, congruence with symptoms...

Documents