Kim T Mueser Center for Psychiatric Rehabilitation Boston University With contributions by Cori Cather Jen Gottlieb Eric Granholm and Kate Hardy Disclosure All my clothes were made by my son J ID: 612685
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Slide1
Cognitive Behavioral Therapy for Psychosis: A Research Update
Kim T. Mueser
Center for Psychiatric Rehabilitation
Boston University
(With contributions by Cori Cather, Jen Gottlieb, Eric
Granholm
, and Kate Hardy)Slide2
Disclosure
All my clothes were made by my son, J.
Mueser
Bespoke Hand Tailored Suits and Shirts New York City store location:
J.
Mueser19 Christopher St.New York, NY 10014(347) 982-4382http://jmueser.comSlide3
OUTLINE
Ancient and recent history of CBT
Background and basic assumptions of CBT
CBT for psychosis (CBTp): Core ingredients and different modelsResearch on CBTpCBTp
for clients receiving ACTSlide4
FOCUS ON COGNITIVE MODELS OF PSYCHOLOGICAL ADJUSTMENT
“People are not disturbed by things, but by the view they take of them.”
Epictetus (AD 55-135)Slide5
Human beings can alter their lives by altering their attitudes of mind…. Be not afraid of life. Believe that life is worth living and your belief will help create the fact
.
William JamesPioneering American psychologist and philosopher
1842-1910
5Slide6
ALBERT ELLIS – RATIONAL EMOTIVE BEHAVIOR THERAPY
6
Innovative straight-talk approach to psychotherapy made him one of the most influential and provocative figures in modern psychology and psychiatry
Challenged
the deliberate, slow-moving methodology of
Freud,
the prevailing psychotherapeutic treatment at the time Slide7
ALBERT ELLIS: VIEW OF HUMAN NATURE
Humans are born with potential for both
rational
and irrational thinkingHave biological & cultural tendency to think crookedly & to needlessly disturb ourselves
Learn & invent disturbing beliefs & keep ourselves disturbed through our self-talk
Have the capacity to change our cognitive, emotive, and behavioral processes
7Slide8
AARON BECK – COGNITIVE THERAPY (CT)
8
Noted as one of most influential psychotherapists in changing the face of American Psychiatry since Freud, Beck has enjoyed widespread success and professional recognition as a psychiatrist, theorist, and researcher.
Founder of Cognitive Therapy, a form of psychotherapy that incorporates an information-processing model of human psychology rather than one based on instinct, motivation, or biochemistry. Slide9
AARON (“TIM”) BECK: COGNITIVE MODEL AND PSYCHOPATHOLOGY
Perceptions of situation lead to automatic thoughts which generate emotional, behavioral, and physiologic response: Core beliefs (schemas) underlie automatic thoughts
Situation Automatic Thoughts Emotion
Behavior
Physiologic Response
BeliefsDistorted perceptions and dysfunctional beliefs are major “underlying cause” of emotional and behavioral dysfunction
9Slide10
PRIMARY ASSUMPTIONS UNDERLYING CBT
What you think in a situation influences how you feel in that situation
How you feel influences your behavior, or how you act in that situation or related situations in the future
Sometimes how you feel in a situation influences what you think about itLearning how to evaluate and correct inaccurate thoughts/beliefs related to negative feelings can reduce those feelings and lead to more effective behaviorSlide11
EXAMPLE
You are walking down the street one day and you see a friend on the other side of the street. You call out to say “Hi,” but he doesn’t respond.
How would you feel in this situation?
How might you behave the next time you saw your friend?Slide12
Thoughts
Behavior
Mood
Nobody likes me
I am a failure
People want to hurt me
Isolation
Avoidance
Procrastination
Depression
Anxiety
Fear
THE COGNITIVE-BEHAVIORAL MODELSlide13
THE NATURE OF COGNITION
Early experiences lead people to develop core beliefs
From core beliefs unhelpful assumptions are generated that organize perception and govern behavior
Critical incident triggers the assumptionsLeading to negative automatic thoughts, which impact mood, behavior and physiology Slide14
BASIC TENETS
OF CBT
CBT
usually
focuses
on the presentCollaborative,
time-limited
,
structured
Emphasis
on goals, problem-solving, and skill
acquisition
Focused
on decreasing distress in the service of improving
functioning
Clients
learn specific skills such as identifying and modifying distorted thinking and using approach rather than avoidance behaviors
14Slide15
BASIC TENETS OF CBT
(
Cont
’d)
Insight alone does not produce
change
Uses
‘
guided discovery
’
rather than giving advice (“Socratic Questioning”)
Homework is given between sessions – skill generalization is key
Clients are encouraged to “become
your own therapist”
15Slide16
HISTORY OF CBTp
First described by Beck (1952)
However …
Largely overlooked as an intervention for psychosis Prominence of biological/medical modelsStudies in the 1980
’s that reported talking therapies as damaging to people with psychosis Long held assumption psychosis lies outside of realm of ‘normal psychological functioning’ Slide17
RATIONALE FOR
CBTp
Persistent psychotic symptoms present in 25-40% of persons with schizophrenia
Persistent psychotic symptoms predict relapses
and rehospitalizations and longer hospital stays
High distress, depression,
demoralization
associated with persistent psychotic symptoms
Barrier to community adjustment, especially social relationshipsSlide18
FOCUS
OF
CBTp
CBTp focuses on reducing the
distress caused by
psychotic symptoms, including hallucinations and unusual thoughtsAlso focuses on
supporting functioning
by addressing negative symptoms
The interpretation of the event causes distress rather than the event itself
CBTp
involves checking the accuracy of interpretations of events
CBTp
examines how current behaviors are
maintaining the
problem
N
eed
to check the helpfulness of current behaviors Slide19
OTHER TARGET AREAS FOR CBTp
S
ymptoms of depression and anxiety
Past traumatic events Social skills Negative symptoms including lack of motivationProblem solving and decision makingDeveloping coping skills
Relapse prevention planning Slide20
CBTp
PHILOSOPHY
Not so different from CBT for depression and
anxiety
Human experience and behavior exists on a continuumPsychotic symptoms (and other schizophrenia symptoms) are amenable to cognitive and behavioral interventions
Reduction of symptoms/distress tied directly to personal goalsSlide21
THE COGNITIVE-BEHAVIORAL MODEL OF PARANOIA
Thoughts
Behavior
Emotions
I’m in danger
People cannot be trusted
I’m an outsider
People want to hurt me
Paranoia
Social Isolation
Avoidance
Hypervigilence
Safety BehaviorsSlide22
MAIN TENETS OF
CBTp
Symptoms are maintained by appraisal and behavior
Distortions are amenable to cognitive and behavioral approaches
Psychotic symptoms (e.g., delusions) represent an attempt to make sense of negative affectSlide23
CBTp
BASIC COMPONENTS
Time-limited nature
Collaboration
Focus on client functional goals (not just subjective states) “
Normalization
”
of symptoms and psychotic experiences
Shared case formulation/conceptualization
Assessment precedes intervention
Socratic questioning
Routine monitoring of outcomes
Homework
Use of indigenous supportsSlide24
COMMON
CBTp
TECHNIQUES
Cognitive Restructuring
Coping Strategy Enhancement
Activity Scheduling Linking Homework Assignments to Session ContentSlide25
RESEARCH ON
CBTp
Over
50
randomized controlled
trialsMost studies conducted with outpatients
Length of
CBTp
treatment typically 6-12 months
Most participants had residual
distressing
psychotic
symptoms,
despite some treatment with antipsychotic medication
Disorganization
was
sometimes an
exclusion criterion
Active substance use
was
sometimes an
exclusion criterion
Multiple meta-analyses, some debatesSlide26
META-ANALYSIS DEBATE
Jauhar
et al. (2014
)Applied stringent masking to analysis and exploration of publication bias
CBT has an effect on ‘schizophrenic symptoms in the “small” range
Note problem of lumping together CBTp studies with different foci on different symptoms or functional areas (e.g., psychotic symptoms vs. social impairment) (Mueser & Glynn, 2014)Turner et al. (2014)
Comparison
of psychosocial treatments for psychosis
CBTp
significantly more effective (p<0.05) in reducing positive symptoms than other PSI (befriending and supportive
counseling
)
Social
skills training more effective in reducing negative
symptomsSlide27
META-ANALYSIS
DEBATE (Cont’d)
Burns et al. (2014
)Meta-analysis for medication resistant positive
symptomsES 0.47 (positive symptoms)
and 0.52 (general symptoms) at end of treatment Patients with medication resistant positive symptoms may derive more benefit from an adjunctive psychotherapy… than from adjunctive medications Slide28
META ANALYSIS OF
CBTp
RCTs WITH PERSISTENT POSITIVE SXS DESPITE ADEQUATE MEDICATION TRIAL (N = 639)
Effect size (g)
(Burns et al, 2014)Slide29
SUMMARY OF EFFICACY DATA
Specific, superior small to medium effect on positive symptoms
Medium effect on all symptoms
Improves overall functioning
Reduces time in the hospital
Effects are durable over follow upSlide30
CONSENSUS GUIDELINES THAT RECOMMEND
CBTp
AS A BEST PRACTICE
U.S.:
Schizophrenia
Patient Outcomes Research Sweden:
National
Board of Health and Welfare
U.K.:
National
Institute for Health
& Clinical
Excellence
Canada:
Canadian Psychiatric
AssociationSlide31
BEST PRACTICE GUIDELINES
“
Persons with schizophrenia who have residual psychotic symptoms while receiving adequate pharmacotherapy should be offered adjunctive cognitive behaviorally oriented psychotherapy to reduce the severity of symptoms The therapy may be provided in either a group or individual format and should be approximately 4-9 months in duration. The key elements of this intervention include the collaborative identification of target problems or symptoms and the development of specific cognitive and behavioral strategies to cope with these problems or symptoms.
”
(PORT, 2009)Slide32
DO YOU HAVE TO BE AN EXPERT TO DELIVER
CBTp
?Slide33
THE SHORT ANSWER IS “NO”!
Trained BA level case managers to deliver “high yield
CBTp
interventions” in an open trial
5-day intensive training with weekly supervisionCBTp
rated as delivered competently
Positive outcomes on negative and general symptoms, hallucinations; no effect on delusions or social functioning
Encouraging preliminary data on dissemination potential
(Turkington et al, 2014)Slide34
CBTp FOR ACT CLIENTS
ACT services reserved for clients with most severe mental illnesses:
Prominent” treatment-refractory” psychotic symptoms common
High utilization of inpatient servicesDifficult to engage in traditional mental health servicesACT has the potential to improve functioning in clients receiving ACT, reduce time to transition to less intensive services
Limited efforts to implement CBTp on ACT teams thus far
Recent attempt to evaluate CBSST for clients on ACT teamsSlide35
Implementation of
Cognitive-Behavioral Social Skills Training (CBSST) on Assertive Community Treatment (ACT) Teams:
Barriers, Facilitators and Outcomes
Eric
Granholm
, Gregory Aarons, Kim Mueser,
Dimitri
Perivoliotis
, Jason Holden, David
Sommerfeld
& Peter LinkSlide36
3 CBSST
MODULES
Cognitive Skills Module
3C’s; Behavioral experiments Mistakes in thinking (All-or-None, JTC)
Target defeatist performance attitudesSocial Skills ModuleFour basic communication skills
Meet friends, ask for dates, roommate conflict…Thoughts about skill performance/successProblem Solving Skills ModuleFive-step problem solving training (SCALE)Social functioning/recovery goal steps
Thoughts about performance/success
36Slide37
5-YEAR HYBRID TYPE 1
EFFECTIVENESS & IMPLEMENTATION TRIAL
Effectiveness
: Randomized controlled trial of N=178 clients with
schizophrenia or schizoaffective disorder in ACT vs. ACT+CBSST
85 randomized to ACT+CBSST:Program 1 = 13, 19, 15 per team (N=47)Program 2 = 8, 11 per team (N=19)Program 3 = 9, 10 per team (N=19) ACT teams delivered adapted CBSST for up to 18
months
Implementation:
Structured, mixed qualitative-quantitative methods (i.e., Concept Mapping)
Focus groups characterized implementation experience from multiple stakeholder perspectives (i.e., consumers, providers, supervisors, agency & CMH administrators)
37Slide38
ACT-CBSST
PROVIDERS
N=97 providers (min 6-mos at agency)
7
ACT teams, 3 CMH agencies/
programsOne-day workshop (max would allow)
Weekly
30-min consultation
meetings
Session
audio recordings rated for fidelity (CTS-
Psy
) with provider feedback (N>600
)
CBSST
resource website with videos of workshop & role plays demonstrating skills, PowerPoint didactics, handouts
38Slide39
PROVIDER CHARACTERISTICS (
N=97)
78% Female; 68% White; Age M=32.9 (SD=8.4)
Discipline: Education:
Psychology 24% <MA 52%
Social Work 17% >MA 48% MFT 13% No Psychologists
SUD Counsel 8%
Nursing 5%
Voc
/Train/CM 31%
6% licensed
Time at agency: M=16.8
mos
(SD=26.6)
39Slide40
TOTAL CBSST SESSIONS RECEIVED BY
CL
IENTS (N=85)
40
Mean=14.2
Median=13
SD=10.4
Range =0-52
Q1: 0-5
Q2: 6-13
Q3: 14-21
Q4: 22-52 Slide41
CTS-PSY FIDELITY FOR PROVIDERS WHO DELIVERED SESSIONS
41
M
CTS-Psy fidelity rating = 36.2 (
SD
=7.1, Range 15-48); 30 is considered adequate (85%>30)
Good Fidelity
*Slide42
KEY IMPLEMENTATION FACTORS
Ongoing Training Feedback and Support
Regular expert consultation and coaching, timely fidelity feedback, access to training resources, training that bolsters EBP confidence
Organization and Team SupportsProtected time, systems to monitor and prompt delivery, team/agency leadership prioritization and supports, outcome monitoringFit between ACT and CBSST models
Adaptations for team and community delivery, flexibility for complex clients and crisis management model
42Slide43
PRELIMINARY OUTCOMES
43Slide44
SKILL KNOWLEDGE OUTCOME
44
Time:
p<.001
Group X Time:
p=.024
Granholm et al.,
JCCP
, 2014
d
= .35
d
= .72Slide45
FUNCTIONING OUTCOMES
Data under analysis
d
= .29
d
= .15Slide46
TENTATIVE CONCLUSIONS
CBSST could be implemented on ACT teams, with good fidelity
Difficult to get sufficient dosage of CBSST
Was having different practitioners work with the same client a limitation on developing a working alliance in delivery of CBSST?Clients demonstrated learning of core skills taughtSome evidence of improved psychosocial functioning
46Slide47
TARGETING PSYCHOSIS WITH
CBTp
AND OTHER EBPS ON ACT
CBTp is important tool for working with clients with persistent psychotic symptomsOther EBPs may also reduce psychotic symptoms and improve functioning among ACT clientsDifferent interventions may work for different clients
ACT teams need to provide access to multiple EBPs to serve these clientsExample: Supported Employment and Illness
Management and Recovery (IMR)
47Slide48
ILLNESS MANAGEMENT AND RECOVERY (IMR)
Focuses on helping people set recovery goals and achieve those goals through learning improved illness management information and skills
Extensive, standardized curriculum taught with
psychoeducational, motivational, and CBT techniquesShown to improve course of severe mental illness, including reduction of hospitalizations in clients receiving ACT services (
Salyers et al., 2011)
48Slide49
SUPPORTED EMPLOYMENT
Practical help for getting and keeping competitive jobs for clients who want to work
Shown to be more effective than other vocational programs, including for ACT recipients (Gold et al., 2004)
Employment associated with modest reductions in psychotic symptoms (Bell, Bond, Mueser studies)
In 5-year RCT, more clients in supported employment worked in competitive jobs, were less likely to be hospitalized, and had better quality of life than those receiving usual vocational services (Hoffman et al., 2015;
Jackel et al., 2017)Higher employment rates mediated reduced risk of relapse and improved quality of lifeWork may be good therapy
49Slide50
CONCLUSIONS
CBTp
targets
distress related to psychotic symptoms, and other symptoms and functioningA strong evidence supports
CBTp for persons with SMI, and it is recommended by multiple national guidelines for schizophrenia
CBTp is based on CBT psychotherapy model, which emphasizes the role of thinking and beliefs in influencing how people react to eventsLimited efforts have focused on implementing CBTp on ACT teams, but it has great potential to improve functioning in this population
50