Psychosis:
Counseling the Hallucinating or
Delusional Patient
Presented by Ron Broughton, M.Ed., L.P.C.
Chief Clinical Officer
Brookhaven Hospital
Tulsa, Oklahoma
Objectives
1. Overview of medications & efficacy
2. Historical examination of the role of
psychotherapy with psychotic patients
3. Review recent research of CT/CBT
4. Learn specific therapy strategies for
psychosis
5. Overview the of ABC model
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.”
Charlie Brown’s View
2010 $16 billion on
antipsychotics
Reduce positive and improve
negative symptoms
Less overall side-effects
Examples: Clozaril,
Risperdal,
Zyprexa, Seroquel,
Geodon, Abilify,
Saphris, Fanapt,
Latuda & Invega
25-50%
Still experience symptoms
May facilitate CT & CBT
Research on Psychotherapy
and Psychosis
Three Recent Eras
Psychotherapy 1960-1975
Medication
vs.
Therapy
Medication Superior
Focus
On
Problem Solving
Experienced
Therapists
Better Outcomes*
Psychotherapy 1980-1995
Compares Forms of Therapy
Intensive = no advantage?
Supportive & insight less meaningful
*Strong alliance = better med compliance &
outcome
The Early Theme
1.
2.
3.
4.
Psychodynamic approaches not effective
Strong therapeutic rapport
Personal therapy more effective
Experienced clinician + individualized
approach = better outcome
An Evolution Begins
Creativity is a drug I cannot live without.
--Cecil B. De Mille
Evolvement in the Late 90’s
The Late 90’s Results
Personal
Therapy
Experienced
Clinician
CBT Emphasis
Positive
Outcome
Compared to supportive & psychoeducational treatment
Don’t Forget Your Favorite College Course
CBT Research & Hallucinations
Reduces & decreases severity
CBT Research & Hallucinations
Increases quality of life
CBT Research & Hallucinations
CBT
Family
Therapy
Integrative Approach
CBT Research & Hallucinations
Overall, CBT
IMPACTS
Hallucinations
CBT Research & Delusions
Studies Have Mixed Results
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
Client Satisfaction
Was treatment positive/helpful?
•CBT = 70% “Yes, definitely”
•ST = 37%
•TAU = 30%
Reason unclear, perhaps the therapeutic relationship?
Strategies
Strategies
Establish a strong therapeutic rapport
Strategies
1. Stress reduction
2. Relaxation techniques to stabilize
3. Systematic desensitization to stabilize
4. 5,4,3,2,1 to stabilize
5. Normalize the experience
6. Do Not use “delusion, hallucination,
psychosis”
7. Know the belief well
Strategies
8. Verbal challenge—the evidence
9. Voice logs
10. Client write out delusional content
11. Evidence logs
12. Change topic if client agitated
13. Relapse prevention plan
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
5. Walk in the delusion, don’t collude with it
6. Restrict use of silence, or watch the eyes
7. If agitated, go to a neutral topic
1.
2.
3.
4.
The ABC Model for Psychosis
The Philosophy
Noumenon
An object as it is in itself, independent of the mind.
The Philosophy
Our reality is interpreted through our senses & beliefs,
The “B” of the ABC Model
Delusions on a Continuum
Less
Normal
More
All of us fall on the continuum.
5 Principles of the ABC Model
1. All clinical problems are C’s.
2. Problems arise from B’s not A’s.
3. There are predictable connections
between B’s and C’s.
4. Core B’s arise from early experiences.
5. Weakening beliefs weakens associated
distress & disturbance.
Eight Basic Steps
1.
2.
3.
4.
Client defines a problem
Assess A or C
Assess the one that remains
Connect A to C & determine that is the
clients primary worry
5. Assess beliefs, inferences & evaluations
Eight Basic Steps
6. Formulation:
 Show the B-C connection
 Offer a developmental formulation
7. Set client’s goals & consider his options
–
–
–
–
Avoid or escape
Do nothing
They can change them in some way
Reduce by changing core beliefs
Eight Basic Steps
8. Challenge beliefs
 Disputing and testing inferences
 Disputing and testing evaluations
Note: this is sequence of conceptual steps, not of technical
ones. Lengthy & dynamic process.
Case Study #1
1. Delusional set
 Excessive religiosity
 Minimal ADL’s
 Reading the Bible and prayer only
2. Interventions
 Assessed A’s
 Assessed C’s
 Assessed B’s (inferences, evaluation & interpretation)
 Challenged B’s
 Family therapy
Case Study #2
1. Indeterminate delusional set
 Highly intelligent
 Mathematics wiz
 “Word salad”
2. Interventions
 Assessed A’s
 Assessed C’s
 Unable to assess B’s
 Focused on health & safety
Review
1. Brief overview of medications & efficacy
2. Historical examination of the role of
psychotherapy with psychotic patients
3. Review recent research of CT/CBT for
psychosis
4. Learn specific therapy strategies for
psychosis
5. Overview the ABC model
Some Conclusions
1.
2.
3.
4.
5.
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
6. ABC model and schema therapy
Questions?
Thank You!