Person-Based Cognitive Therapy
for Distressing Psychosis
Prof Paul Chadwick
Royal South Hants Hospital &
University of Southampton
PBCT, like CT for psychosis,
targets distress, not symptoms
• In Cognitive Therapy for delusions, Voices, &
Paranoia, Chadwick, Birchwood & Trower (1996)
literally defined psychological problems in terms
of distress & behavioural disturbance
• ‘This definition of problems in terms of distress
and linked behaviour is one of the greatest
strengths of the cognitive model. What most
clients have been told by other professionals is
that they do have a problem – it is their
symptoms’ (1996, p. 2)
No distress, no CT
• If person not distressed by symptom, then
not a problem & no rationale for CT
• Commitment to easing distress is basis for
collaboration:
‘The cognitive therapist has to convey that
her interest is in the client’s emotional and
behavioural problems…cognitive therapy
presumes a common focus for change –
emotion and behaviour’ (1996, p. 47)
Distress is cognitively mediated
severe emotional disturbance
• Loss – deep sadness is healthy human
response, not a problem
• Depression & suicidality = distress
• Defining attribute of CT is mediational
understanding of distress
• In 1996 we stated: Distress not a direct
consequence of psychotic symptoms, but
mediated by meaning
From Symptom Model to a Person
Model
• Early 1990s saw a Paradigm shift from Syndromes to
Symptoms: Bentall, Boyle, Garety…
• In 1996 we called for a further paradigm shift, from
Symptom Model to a Person Model
• Symptom model transitional: (i) for each symptom,
competing models, none proven, probably different
pathways, (ii) multiple psychotic symptoms, (iii)
depression, anxiety
• Person model needed to give overarching theoretical
and therapeutic framework to hold & work with range of
clients’ experience
• Person-Based Cognitive Therapy for Distressing
Psychosis, (2006: Wiley) is my progress over the past
decade in this direction
Main Developments in PBCT
1. Greater emphasis on person-centred
therapeutic relationship
2. New case formulation: Vygotsky’s Zone
of Proximal development
3. Mindfulness
4. Development of work on schemata
5. Metacognition is a central concept
(Teasdale, Wells, Morrison)
Therapeutic Relationship In PBCT
‘I feel deep concern that the developing
behavioural sciences may be used to
control the individual and to rob him of his
personhood. I believe, however, that these
sciences might be used to enhance the
person’
(Rogers, 1961, p. 362)
At times CBT for Psychosis not
Client Centred
• Supervision, listening to tapes, case
discussions – easy to not be personcentred with clients with psychosis
• Might be Rogerian for 1 or 2 sessions then
‘switch mode’, or ‘change gear’
• Therapists pushing an agenda, pushing
techniques…controlling clients
• Well-intentioned, & methods were CBT
• Something wrong with context
Understanding Therapist’s
Anxieties, fears and worries
• Work in pairs.
• Explore moments of anxiety, fear and worry you
experience when working with (or imagining
working with) clients with distressing psychosis
• What are the implicit/underlying worries, beliefs
& assumptions? (e.g. client might not change)
• How might these assumptions affect (i) your
behaviour with client (ii) therapeutic
relationship?
Understanding Therapist Anxiety
• Burns & Auerbach (1996) in Frontiers of
Cognitive Therapy: therapists’ feelings
reflected (at least in part) therapists’ own
beliefs
• When explored this anxiety in s/v kept
meeting in myself & others anticollaborative assumptions about how
therapy should progress
A universal anti-collaborative
assumption?
• Therapist’ fear of failure: A universal anticollaborative assumption?
• Participation: “My client must not drop out of
therapy, I am responsible for keeping the person
in therapy”
• Change: “My client must change, I am
responsible for change, I must get the person to
change. Therapy has meaning only if the person
changes”
• Assumptions, just like clients, are written in
therapists’ behaviour and affect
Alternative stance:
Radical Collaboration (RC)
• RC: A therapeutic stance free from
assumptions about how therapy should
progress (Chadwick, 2006)
• CBT expression of Rogerian personcentred relationship
• NOT passive – use all methods of CBT, it
is about how they are used
Remaining Radically Collaborative
1. Awareness of emotional arousal in therapy
2. Supported (Guided) Discovery: ‘neither
challenge head on, nor avoid’
3. Articulate assumptions that support RC: ‘My
responsibility is to RC & acceptance of
whatever therapeutic process unfolds’
4. Set linked personal goals
5. Behave in ways that support RC & fly in face of
anti-collaborative assumptions
6. Self-acceptance
Formulation in PBCT
PBCT needs a formulation framework that:
1. makes sense of diverse sources of
distress
2. supports therapists to remain radically
collaborative & person-centred
throughout the process of therapy –
supporting relationship as well as
possible outcomes
Case Formulation: Zone of
Proximal Development (ZoPD)
• Central CF in PBCT is Zone of proximal
development based around four distinct
sources of distress, and therefore wellbeing
• Vygotsky: What is a ZoPD?
• For Vygotsky: Development is a social,
collaborative process
Formulation: Zone of proximal
development
Symptomatic
meaning
Relationship
to internal
experience
RC
RC
Domains of
Proximal
Development
RC
Schemata
RC
Symbolic
Self
ZoPD & Understanding
• ZoPD used by therapists to help
understand diverse sources of distress
• Be flexible and respond to client
presentation in a client-centred way
without floundering or feeling lost
• Usually shared as letter (CAT)& formulate
domains – e.g. formulation of schemata,
ABC formulation of persecutory beliefs
Formulation Letters
1.
Authentic positive statements about therapists’
experience of client - strengths, attitudes and attributes
2. ZoPD framework used flexibly to reflect on, clarify and
organise a person’s current sources of distress
3. Positive alternative rules and schemata are included
4. Clear views are expressed about possible
collaborative proximal development (aims), ideally in
all four domains
5. Likely threats to the person achieving his or her aims
are also drawn out, based on the formulation.
6. Explicit reference to personal life strengths, qualities, &
achievements in life (familial, occupational, spiritual, or
social)
[From Cognitive Analytic Therapy: CAT, Ryle, 1979)
Integration of Mindfulness
• Relationship to internal experience
• In the moment of experiencing a voice,
vision, tactile sensation, paranoid
intrusion, how does the person react?
• CBT focus & mechanism of change is
meaning; with Mindfulness it’s relational
Differences from MBSR & MBCT
• Only seated mindfulness grounded in breath
& body - not yoga, walking, eating or Body
Scan
• Mindfulness practice only 10 minutes long
• All practice guided with regular comments, at
least every minute
• Homework encouraged, & with guided tapes
• Context – severe distressing psychosis,
therapy not skills ‘class’
• If practise in group, maximum 8 per group
Relating mindfully to psychosis
Introducing Mindfulness to Clients
1. How does person cope presently?
2. Can these be grouped into either avoiding or
getting lost in a reaction?
3. Explore effectiveness (pros & cons) of each
4. Locate M as middle way
5. Invitation in M practice ‘let go’ of other coping
& see how it is: Behavioural Experiment
6. Outside therapy, M as additional method, not
asking to abandon existing coping
Clients don’t stop reacting
Times of being mindful, times of reacting
Mindful with some voice comments, not
others: Steven:
• voice says ‘leave the group’ now sits still &
mindful.
• voice says ‘kill yourself’ or ‘harm others’,
he fights them
Metacognitive Beliefs make
Mindfulness Difficult
Metacognitive Beliefs maintain avoidance,
reacting, judging, ruminating & confronting, and
make it difficult to be mindful
MB 1: “Letting Go means losing experience”
Damien: ‘You don’t mean letting go of
everything, do you. If you let them go all the
time, what have you got left? Nothing.’
Metacognitive Insight: Letting go of reactions
brings experience into clearer focus
Testing Metacognitive Belief
• MB 2: “Unless I continue to fight and struggle I
will be overwhelmed, defeated or harmed”
• Mindfulness practice is offered as a behavioural
experiment to test metacognitive beliefs
• ‘Would you be willing to test this out, to see if
you can not fight and swear at the voices just for
these few minutes of practice, and see how that
feels?’
• Metacognitive Insight: ‘In moments when I can
let go of fighting and struggling, and be mindful, I
feel calmer, peaceful’
Seeing my role in alleviating
distress
The metacognitive insight emerges that
Reacting creates distress.
Martin: ‘You can either let them go, or after
20 minutes you’re going to be screaming,
breaking windows, throwing your shoes
against the wall, banging your fists against
the wall. Which one is preferable?’
CBT skills facilitate this development
Mindfulness within PBCT
Experiential development within Mindfulness
domain summed as moving
From metacognitive belief:
‘I can never find happiness until I am rid of these
voices, thoughts, images’.
To metacognitive insight:
‘I can find happiness and peace if I can be
aware and accepting of these unpleasant
experiences as they are’.
John: ‘It’s not so much control the voices, as be
more peaceful with them’.
Process of Change
• Abba, Chadwick & Stevenson (2007:
Psychotherapy Research, in press)
• Grounded theory analysis of experience of
first 16 clients to attend a mindfulness for
distressing psychosis group
• Responding mindfully to unpleasant
psychotic sensations involves establishing
a new relationship with psychosis
Learning to respond mindfully to
psychosis
Centering in awareness of
psychosis as it arises
Opening
awareness to
include the
unpleasant
Beginning
again and
again
Allowing voices, thoughts &
images to come and go
without reacting/struggle
Letting go of
judgement, fight,
worry, analysis
Seeing my role in
alleviating
distress
Reclaiming my power through
acceptance
Accepting
voices,
thoughts &
images
Accepting
myself
Self
Concerns domains 3 & 4 of ZoPD
• Schemata: negative & positive self-schemata
• Symbolic Self
• Experiential methods used in both domains
• Influenced by important book on two-chair
methods:
Greenberg, L., Rice, L. & Elliott, R. (1993).
Facilitating emotional change: The moment-bymoment process. Guilford: New York.
Experiential work with schemata
1. Decentred awareness of NSS: Getting to
know it, how it feels…
2. Metacognitive insight into impact of NSS
3. Acceptance of NSS experience, as part
of the self, not the self – Question
‘global, stable’ quality only
4. Development of PSS (Padesky…)
Symbolic Self
(Fourth Domain of ZoPD)
•
•
•
•
A goal in the other domains of the ZoPD
acceptance of unpleasant psychotic
sensations & experiences of NSS
Symbolic Self domain: goal is self-acceptance
Basis for this self acceptance is metacognitive
insight into self as complex, contradictory,
changing process
For example, two-chair process: negative &
positive schematic experiences both lived, side
by side
Aims of Two-chair Method
1.
2.
3.
4.
Bring NSS into decentred awareness
Metacognitive insight into impact of NSS
Draw out PSS
Promote Rogerian acceptance of both – not
get rid of NSS, but accept as experience of
self
5. Metacognitive Insight into nature of self as a
complex, emotionally varied, contradictory,
changing process (Symbolic Self)
Chair 1: Enact NSS
• Process of decentring starts with enactment of NSS
• NSS is expressed as ‘I am…’ to stress experience of
self & not align with voices
• Brief, but not too brief (5 mins)
• Not emotional flooding: Contained emotional
experience
• Stay with phenomenology in situation: no link made
to early experience…
• In everyday life clients do not experience their NSS
in the way shown in video clip: How is it therapeutic?
Negative Self-schemata (NSS)
• Helen Kennerley: HCB; Rules & linked
interpersonal behaviour; person evaluations
(o-s, s-s, s-o), future, body image & posture
• Chadwick et al (1996) stress global, stable
phenomenology: whole self that is flawed,
bad & cannot change, it is who I am –
hopelessness
• Emotionally hot experience of self - Not
experienced as belief or construction
• Drop of ink in a glass of water
MI into impact of NSS
‘It helped to physically shift from being in those
destructive, negative feelings, to looking at
them from an outside point of view’
“I realised how badly I felt, how the negative state
was no good for me, was not working.
Attending only to the negative paralysed me. It
was getting me down and eventually would
have worn me away”
Chair 2: Positive Self-Schema
• Same attributes as NSS (rules, HCB…)
• Lies in same domain (sociotropy or
autonomy) – not any happy experience
• No time limit
• ‘Lived’ emotionally, adjust posture:
Avoid ‘I must be good because…’
reasoning
• Authentic, realistic, not ‘puffed up’
Rogerian Acceptance of Both
Experiences of Self
• Explicit Rogerian acceptance of both chairs at
experiential level
• It is an undeniable fact that much experience of
self has been & will be that ‘lived’ in 1st chair
• Guided discovery of idea that NSS & PSS have
same experiential validity or ‘reality’
• State that not trying to get rid of NSS, but rather
make space for all experience, which includes
PSS
Metacognitive insight into Self
•
•
•
•
•
•
PSS & NSS both person’s own experience
Have equal phenomenological reality
Accept & integrate in new Symbolic Self
Self seen as complex, contradictory and
changing process
Challenges global & stable quality of NSS
‘Once you get one good bit, that’s okay,
there are always possibilities of other bits.
And the negative is not going to be all the
time, all my life’
Maintenance & Generalisation
• Repeated flexible use of two chair method
is crucial
• Standard methods to support maintenance
& generalisation of PSS (e.g. Padesky)
• Not about getting rid of NSS experience of
self
Rogerian Self Acceptance
• “One of the fundamental directions taken by the
process of therapy is the free experiencing of the
actual sensory and visceral reactions of the
organism without too much attempt to relate
these experiences to the self…The end point of
this process is that the client discovers that he
can be his experience, with all of its variety and
surface contradiction: that he can formulate
himself out of his experience, instead of trying to
impose a formulation of self upon his
experience, denying to awareness those
elements which do not fit’ (Rogers, 1961, p. 80)
In summary, PBCT for psychosis…
• Seeks to support clients to understand and
alleviate distress & disturbance, & move
towards well-being, acceptance of
psychosis & self-acceptance.
• Does this through integrating CT, Rogers
& mindfulness within one clear organizing
framework - Vygotsky’s ZoPD
References
• Chadwick, P.D.J. (2006). Person-Based Cognitive
Therapy for Distressing Psychosis. Wiley
• Greenberg, L., Rice, L. & Elliott, R. (1993). Facilitating
emotional change: The moment-by-moment process.
Guilford: New York.
• Kabat-Zinn, J. (1990). Full Catastrophe Living. Dell: NY.
• Salkovskis, P. (1996). Frontiers of cognitive therapy.
• Segal, Z. V., Williams, J. M., & Teasdale, J. D. (2002).
Mindfulness-Based Cognitive Therapy for Depression.
Guildford: NY.
• Teasdale, J. et al. (2002) Metacognitive awareness and
prevention of relapse in depression: Empirical evidence.
JCCP, 70, 275-287.