Early Intervention in Psychosis
‘At Risk Mental States’
Cognitive Therapy for People at High-Risk of
Developing Psychosis
Dr. Aoiffe Kilcommons
Dr. Sophie Parker
Clinical Psychologist
Clinical Psychologist
Framework of CT for ARMS
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Cognitive therapy main intervention
However it can be helpful to interweave
alternative interventions
Use of case management skills such as
assistance with housing, bills, negotiations
with college/employer/neighbours.
Crisis intervention skills at times such as
becoming homeless, traumatic events etc.
Encourage strategies to manage these
crises.
Intervention Process
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Develop therapeutic relationship
Assessment
Establish shared problem list
Translate into ‘smart’ goals
Formulation
Interventions derived from formulation
Relapse prevention
Engagement
Practical
• Offer flexible appointments, time and venue
• Rapid response to referral
• Consistency
Therapy
• Socialise to cognitive model, focus on distress
• Success early in therapy
• Problem orientated
• Collaborative, shared, prioritised, SMART goals
• Language
• Incorporate case management strategies
Common Themes in EDIE 1 Problem Lists
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(French and Morrison,
2003)
Anxiety
- I’m going mad / identity
- Social anxiety
- Worry & metacognition
- PTSD
Mood & activity
- Boredom / depression / hopelessness / self-esteem
- College/job/money
Social Networks
- Relationships – friends, family, partners
- Loneliness / lack of confidant
Problems
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“I
“I
“I
“I
“I
“I
“I
“I
“I
“I
am unhappy with where I live.”
feel anxious and paranoid when I leave the house.”
worry that people know what I’m thinking”.
feel depressed.”
worry about people laughing at me when I go out.”
need to get a job.”
want more money.”
have difficulties expressing myself”.
want to know what is wrong with me.”
need a girlfriend.”
Goals
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When I go out, I would like to be able to distinguish with
more certainty if people are laughing at me or whether I just
feel this is the case (reduce distress from 60% to 30%).
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To begin to understand if what I am experiencing is the start
of psychosis.
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To find out what alternative accommodation is available and
contact various housing agencies in order to get on their
waiting lists.
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If I felt less anxious I would like to be able to leave the
house and go to the local shops when I felt like it (and at
least 3 x a week).
Intervention Strategies
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Formulation
Normalisation
Working with metacognitive beliefs
Generating possibilities for intrusions
Safety behaviours
Selective attention
Activity scheduling
Relapse prevention
Formulation
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The formulation using the intrusions
model (Morrison 2001) is developed
within sessions 1 & 2.
The aim is to help the person make sense
of their experiences in more rational and
less distressing ways
One aim of this process is also to
highlight occasions when their
interpretations may not lead to distress.
CT for ARMS: Morrison’s cognitive model of psychosis
Morrison, A. P. (2001) The interpretation of intrusions in psychosis: An integrative cognitive
approach to hallucinations and delusions. Behavioural and Cognitive Psychotherapy, 29, 257-276.
What happened
Event /intrusion
How I make sense of it
Beliefs about yourself
and others
What do you do when this
happens
Life experiences
How does it
make you feel
CT for ARMS: Client friendly version of Morrison’s cognitive model of psychosis
What happens
Worry about what people think about me
See people in street mumbling
The way that I make sense of this
Other people talk about me in a negative way
People mumbling are really swearing at me
What I do
Listen out for people talking
about me
Keep head down
Put glass against the wall
Punish self for bad thoughts
Beliefs about myself and others
I am not a good person
You must be on your guard
Other people are out to get you
Paranoia keeps me safe
Life Experiences
Very religious family
Bullied at school
Parents very over protective
How it makes me feel
Depressed
Paranoid
Angry
What happens
Hear whispering and laughing
See bodies
Think about harming people
What I make of it
I must be going mad
I must not let other people see I am going mad
When mum is drunk she tells me I am going mad
What I do
Try to stay in total control of
thoughts and behaviours
Look out for things
happening to me
How do you understand yourself and
others?
I should be in total control
I am going mad
The symptoms I am experiencing mean I am
going mad
Life Experiences
Have always been interested I what
happens in a psychiatric ward
How it makes me feel
Angry
Agitated
Anxious
Depressed
Fear
What happened
Going out in public
Day dreaming on the bus
What I make of it
Other people people know what I’m thinking
Beliefs about myself and others
I’m odd, weird
Worrying helps me cope
I must be in control of my thoughts at all times
People will look down on me for showing anxiety
How it makes me feel
What I do
Watch out for people looking at me
and giving me strange looks
Worry about it
Experience
Lonely childhood.
Bullied.
Parents separated age 10 years
uneasy
insecure
paranoid
What happens
I saw someone looking at me
What I make of it
They’re watching me
They’re out to get me
What I do
Keep my head down and
don’t look at anyone
Leave the situation
How do you understand yourself and
others?
I’m different from everyone else
I’m weird
My father had mental illness so I might too
Life Experiences
Bullied at school
Father had mental illness problems
How it makes me feel
Racing heart, churning
stomach, sweating,
Anxious, upset
Normalisation
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This uses the existing body of work from
Kingdon and Turkington (1994).
Their strategy allows distress associated
with symptoms to be managed by
normalising the experience.
In our strategy we use the same
approach but more in line with the
intrusions model we utilise a paper by
Rachman and Silva discussing intrusive
thoughts. Thus moving towards a truly
normalising approach.
Metacognition
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The model of psychosis described directs
treatment towards working with
metacognition.
Negative beliefs regarding the appraisal
of the voices as being dangerous or
uncontrollable may give rise to transition
to psychosis.
Generating Alternative Explanations
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As with clients who have established
psychotic symptoms generating possibilities
for the psychotic experience can be
extremely helpful in terms of assessment
and also treatment.
The development of an exhaustive list is
essential, with belief ratings, and emotions
generated associated with this belief.
Subsequently, work through each possibility
generating evidence for and against each.
GENERATING ALTERNATIVE
EXPLANATIONS
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Advantages / disadvantages
Exhaustive range of possible explanations
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Socratic dialogue
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Being creative
Belief ratings for each (0-100%) with
associated emotions
Evidence for and against each one
ALTERNATIVE EXPLANATIONS: Case Example
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Situation: I have been seeing things like dead bodies or
images of myself hung in my wardrobe
Current explanation: I am going mad/ have a brain tumour
Current mood associated with this belief: Frightened
Other explanations
Belief rating
Associated Mood
God is punishing me for
something I have done in a
previous life
40 %
Frightened
Ghosts
75 %
Scared
Brain tumour
100 %
Doesn’t bother me
Going mad
85 %
Depends, okay or
very frightened
Perhaps stress and Kate’s life
90 %
Unsure
EVIDENCE FOR AND AGAINST: Case example
Belief to be examined
I have a brain tumour
Associated Mood
Doesn’t bother me
Belief rating
100%
Evidence for
Evidence Against
• I am having lots of strange experiences.
• People with brain tumours get
progressively worse
• I have been getting better
• I have been learning to make sense of
these experiences
• When I make sense of them they
• People with a brain tumour have
strange
experiences
• I have bad headaches at times
reduce and go away, this would not be
the case if it was a brain tumour
My headaches usually respond to
paracetamol, which would have little
effect on a tumour
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Belief rating (re-rating)
Alternative Thought
70%
Maybe things are more related to
stress which I suppose would also
explain the headaches
Associated Mood
More relaxed
Alternative Explanations: Case example
What happened
Walking through the supermarket
One way of Thinking
“Others can read my mind”
OR
Another way of thinking
“Oh I’m being silly –
it’s not happening”
Things I do
Feelings
Things I do
Feelings
• Look out for
Insecure
Paranoid
Carry on as
normal
Reassured
strange looks
•Worry
Safety Behaviours
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Safety behaviours in the maintenance of
anxiety disorders have been extensively
reviewed.
The model of psychosis presented here
emphasises the idea of self and social
knowledge. Safety behaviours perpetuate
faulty self and social knowledge.
A full exploration of safety behaviours
should be undertaken and these should be
highlighted and experiments undertaken to
test their utility for the client.
Examples of Safety Behaviours
Experience
Interpretation
Safety Behaviour
Saw people laughing
whilst out walking
People in the
street are
talking about
me
To keep head
down, walk fast
and purposefully
Visual hallucinatory
experience, seeing a
man sat on a chair
I am going mad
Not look at the
chair and get out
of the room as
quickly as possible
Shop keeper looking at
me
They know I am
going mad
Said very little (if I
talk it will confirm
I am going mad).
Visual hallucination of
dead body on wardrobe
I am going mad/
losing control
Hide head under
the cover
BEHAVIOURAL EXPERIMENT: Case example
Thought to be tested: When I feel anxious other people will notice my
hands shaking and will think I’m weird and laugh at me.
Belief in thought: (0-100%) Before experiment: 100%
After experiment: 40%
Experiment
to test
thought
Likely
problems
Strategies
to deal
with
problems
Expected
outcome
Actual
outcome
Alternative
thought
Do usual (5
minutes),
exaggerate (5
minutes),
drop (5
minutes)
I will feel
too scared
to do
what’s
asked of
me
Tell my self
that this is
worth a go,
it’s only for
15 minutes
People
will think
I’m weird
I looked
more
anxious
when I
did my
usual
things
Maybe some
things I do
don’t help
me
Selective Attention
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This has been strongly implicated in our
experience of working with this client
group.
Many clients have discussed this as a
means of confirming their experiences in
conjunction with safety behaviours as
indicating they are at risk of impending
psychosis.
Activity Scheduling
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Frequently people are beginning to
isolate themselves, reducing the
frequency and duration of contacts they
have with people and this leads into
further preoccupation with thoughts.
The use of activity scheduling can be a
valuable means of monitoring and
impacting upon activity levels.
Staying Well
• Familiar cognitive interventions
developing blueprint of therapy.
• This should be provided in a medium
which is amenable to the person eg
written or audio tape.
Our Approach
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To increase awareness in primary care
services, secondary care services, voluntary
sector, further education and the community
To increase referrals through:
1. Training for potential referrers
2. Rapid response
3. Flexible approach to client
4. Positive, user friendly service