Cognitive behavioural approaches to
the detection and prevention of
relapse
Staying Well After Psychosis II
Dr Andrew Gumley
Senior Lecturer in Clinical Psychology
University of Glasgow
&
ESTEEM: Glasgow
Schedule
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09-30
09-45
10-15
10-30
10-50
12-00
12-30
13-30
13-45
14-15
14-35
15-15
15-45
Aims and Objectives
Exercise I Rehearsal of Formulation
Feedback
Coffee Break
Prioritising key problematic beliefs and behaviours
Exercise II: Generating alternative strategies
Lunch
Compassionate mind versus rational mind
Exercise III: Developing a behavioural experiment
Coffee Break
Anticipating organisational / service barriers to relapse
prevention intervention
Planning and action points
Discussion and Close
Aims
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This workshop builds directly the skills and themes
developed within Workshop 1. Participants will have the
opportunity to rehearse, revise and / or develop high level
skills in formulation based cognitive behavioural strategies
aimed at recovery and staying well after psychosis. By the
end of the workshop participants will practice skills in
– developing a personal narrative incorporating clients’
experience of psychosis,
– use clients’ narrative to support them in exploring key
personal themes concerning loss, humiliation, entrapment,
fear, threat and shame,
– understand how service and staff interpersonal responses
might alleviate or intensify clients cognitive, emotional and
behavioural reactions to psychosis,
– rehearse cognitive behavioural strategies aims at transforming
such personal meanings, and
– conceptualise systemic interventions aimed at transforming
problematic service responses to signs of elevated relapse risk.
Workshop methodology
 Modelling
therapeutic process
 Where possible, exercises conducted
within clinical teams to aid
dissemination.
 Exercises are designed to specifically
target clinically relevant material.
 Feedback on needs and strengths of
specific exercises.
Therapy scenario
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Th:
Pt:
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Th:
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Pt:
Th:
Pt:
What do you make of your voices?
They’re aliens, they tell me I’m a paedophile, an
abuser, its horrific………
What does your doctor make of these voices,
what does he think they are caused by?
[Pause] He thinks I’ve got schizophrenia.
What do you think about that?
It can’t be true. That would mean I have an
illness, and that would mean these voices come
from me……..[Pause] Those things couldn’t
come out of my head.
Internal,
Personal,
stable
attribution
Attributions
“Jimmy doesn’t get up
cos he’s just being lazy”
Expressed Emotion
Criticism and hostility
Negative self evaluation
Psychophysiological
arousal
Positive Symptoms
Relapse and
readmission
Exercise I
 Teams
 Choose
patient / client from Tuesday
 Rehearse formulation
– Interpersonal context
 Family
and team attributions / responses
– Beliefs
– Emotions
– Cognitive behavioural strategies
Cognitive Interview for Early Signs
Establish last episode (or most
memorable)
 Identify key events
 Prioritise events according to significance
to individual
 Elicit associated memories, images and
other cognitions
 Establish meaning linked to self and self in
relation to illness
 Link event and meaning to cognitive,
perceptual and physiological experience
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Time frame
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ESTABLISH DATE OF LAST RELAPSE
ESTABLISH ONSET OF PRODROME
CHOOSE EVENT DURING PERIOD BETWEEN
ONSET OF PRODROME AND RELAPSE
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Prototypic questions:
When talking about your last relapse is there a
particular memory that comes to mind?
At what point did this occur?
Are their other events which come to mind?
ESTABLISH TIME LINE FOR EVENTS IN
RELATION TO ONSET OF PRODROME AND
RELAPSE
Hot Cognitions
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ESTABLISH EVENT ASSOCIATED WITH ‘HOT’ COGNITIONS
– Prototypic questions:
– Which of these events distresses you most?
– If only one of these events occurred which would have been
the most upsetting?
– Why is that?
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ELICIT MEMORIES AND IMAGES ASSOCIATED WITH THE
EVENT?
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Prototypic questions?
What was so upsetting about that?
Are there thoughts and images which come to mind?
Can you describe these?
GUIDED DISCOVERY TO ESTABLISH MEANING
– What does that event mean to you?
– What was the worst thing about that?
Linkage
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ELICIT COGNITIONS RELATED TO SELF, AND
SELF IN RELATION TO ILLNESS
– What does it say about your illness?
– Do you still think that?
– How does it make you feel about your illness?
LINK EVENT AND MEANING THROUGH COGNITIVE,
PERCEPTUAL, AND PHYSIOLOGICAL EXPERIENCE
– When you think about that now how do you feel? (probe
cognitive, perceptual and physical experience?
– What do / did you notice about your thoughts?
– What do/ did you notice about your body?
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FORMULATE AND SUMMARIZE BY LINKING
EVENT, INTERNAL EXPERIENCES, BELIEFS AND
EMOTIONAL/ BEHAVIOURAL SEQUELAE
Therapist Tasks
 Identify
key cognitions
 Identify key setting events
 Identify key behavioural strategies
 Prioritise
in relation to
– Emotional temperature
– Interpersonal impact
– Day to day impact
Problematic Experiences
Attachments, loss, psychosis etc
Core Beliefs
E.g. I am useless, Others are dangerous
Overdeveloped Behaviours
Underdeveloped Behaviours
Aggressiveness, suspiciousness,
self punitiveness
Self care and nurturance, affiliation,
assertiveness
Pivotal Assumptions
Related to relapse, adjustment and
recovery
 Capture experiential meanings linked to
psychosis and premorbid experiences
 Assimilation and (over)accommodation
 Strongly linked to emotion and “hot”
cognition
 Linked to strategic deployment of
behavioural strategies
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Examples
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If I relapse then my family will be disappointed
If people know how I feel then they will laugh at
me
If I get stressed then I will get unwell
If I do not have complete control of my thoughts
then I am defective
If I seek help then I will be admitted
If I show any signs of weakness then they will
put me in hospital
If I get upset this means I am weak and needy
Exercise II
 Prioritise
– One key belief and associated recurring
behaviour
– Consider carefully the linked associated
valued goals and benefits linked to that
belief and recurring behaviour
– Identify an alternative behaviour that
would achieve person’s valued goal
without same degree of costs.
Rational Mind
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Looks at the evidence
Is scientific, treats thoughts and ideas as theories
to be disconfirmed
Likes to have several alternatives to choose from
Likes to test things and run experiments
Does not like to be hasty
Knows that knowledge develops slowly
Learns from trial and error
Weighs advantages and disadvantages
Takes a long term view
Compassionate mind
Has empathy and sympathy
 Is concerned with growth and reaching
potential
 Is concerned with supporting, healing and
listening
 Is kind and friendly
 Is quick to forgive and slow to condemn
 Does not attack but repairs
 Recognises and accepts imperfection
 Self worth and self acceptance ore not
earned but are unconditional
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Behavioural experiments
 Focus
on target thought and explore
evidence.
 Identify stimuli and behaviours
 Identify alternative belief
 Present rationale for experiment
 Conduct experiment
 Discuss results in terms of
formulation
Specific procedures
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Identify key target belief
– E.g. I am an okay person
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Operationalise cognition
– People are friendly towards me
– People smile at me
– They use eye contact with me
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Alternative behaviour to strengthen new belief
– Giving eye contact to others, smiling etc
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Develop a testable prediction.
– Go into Safeway, at meat counter smile, say hello.
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Consider what can go wrong
– Person ignores me
– They start laughing
Exercise III
 Developing
and planning a
behavioural experiment
– Identify key target belief
– Operationalise belief
– Alternative behaviour to strengthen new
belief
– Develop a testable prediction.
– What can go wrong.
SITUATION
Social situations
INTRUSIONS
Images of being naked
Sexual Intercourse
Bodily hair
METACOGNITIVE APPRAISAL
I’m mixed up
I’m mentally ill
The devil is implanting thoughts in my head
PHYSIOLOGY
Tension
EMOTIONS
Disgust, Shame, Fear,
Depression
SAFETY BEHAVIOURS
Avoidance, Rumination,
Vigilance
Assessment
 Anxious
Thoughts Inventory
 Metacognitions Questionnaire
 Collaboratively developed
assessment:
– Frequency of Intrusions (0-10)
– Intrusiveness (0-10)
– Dwelling (0-10)
– Belief “I am mentally Ill” (0-10)
– Dsitress (0-10)
Questions
What thought would you focus on?
 How would you explore the thought?
 What behaviour would you focus on?
 How is behaviour linked to thought?
 What alternative belief could you test out?
 What could you set up with the patient to
test out the alternative belief?
 What are your predictions for this test?
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Frequency of Intrusions
10
8
6
4
2
0
Days
55
49
43
37
31
25
19
13
7
Frequency
1
Frequency
Frequency
Intrusiveness
12
10
8
6
4
2
0
Days
55
49
43
37
31
25
19
13
7
Intusiveness
1
Intrusiveness
Intusiveness
Dwelling
Dwelling
6
4
2
0
Days
55
49
43
37
31
25
19
13
7
Dwelling
1
Dwelling
8
Belief
Belief
10
Belief
5
Days
55
49
43
37
31
25
19
13
7
0
1
Belief
15
Distress
Distress
5
Distress
Days
55
49
43
37
31
25
19
13
7
0
1
Distress
10
Pre / Post Assessment
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AnTI
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– Social = 28
– Health = 14
– Meta = 23
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MCQ
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Positive = 29
Control = 48
Efficiency = 18
Negative = 28
Self Consciousness =
25
AnTI
– Social = 10
– Health = 7
– Meta = 8
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MCQ
–
–
–
–
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Positive = 29
Control = 20
Efficiency = 10
Negative = 17
Self Consciousness =
17
Contact:
a.gumley@clinmed.gla.ac.uk