Cognitive Therapy for the Treatment of Psychosis/Schizophrenia

March 14, 2010 Presentation by Dr. Neal Stolar,
Clinical Associate Professor of Psychiatry, University of Pennsylvania,
and Medical Director Project Transition, Audubon Program (PA)

Cognitive therapy for psychosis involves training to identify automatic thoughts and examine them to see if they are supported by evidence. For example, a person learns to consider possible alternative explanations for a situation that has triggered a delusion (e.g. consider different possible reasons why people are talking outside your house). If a person changes his or her thoughts in response to a situation, this can change the emotional, behavioral and physiological responses to the situation. In addition to learning cognitive strategies, clients learn coping strategies for dealing with delusions and hallucinations, including distractions (e.g. music) and avoiding situations that are likely to precipitate or worsen delusions or hallucination.

Cognitive therapy for psychosis is generally used in combination with medications. The effectiveness of cognitive therapy in improving symptoms is supported by randomized controlled trials. Cognitive therapy should be distinguished from cognitive remediation/rehabilitation, which is training to improve a person’s attention, memory and executive functioning.

It is important to involve the family for several reasons. Information from family members improves treatment, and family member involvement will help to improve the client’s completion of therapeutic homework. Communication to clear up family members’ misconceptions and suggestions about how best to interact with the client can decrease stress at home, which will help to reduce the client’s symptoms.

Suggestions for Family Members to Help a Relative with Psychosis
(Consistent with a cognitive behavioral therapy approach)

Correcting Beliefs: How we think influences how we feel and how we act. For example, your relative may avoid using the Internet because he believes that voices will come from it, or he may not go to the library anymore because he doesn’t think he’ll enjoy it the way he used to. The best way to correct unhealthy and inaccurate beliefs is through experience, so try to support new experiences that may help your relative “test out” his/her beliefs — e.g., suggest that you go to the library together; suggest things for him/her to do there that might be enjoyable. The worst way to correct beliefs is through direct confrontation, which usually just makes conviction even stronger and increases stress.

When your relative starts talking about his/her delusions/hallucinations:

  • Demonstrate an open-minded, rational approach that is based on facts and evidence, but at the same time empathize with what you can agree on — your relative’s emotional experience. In other words, use empathetic disagreement.

Example: It’s hard for me to see that you’re being threatened because I don’t hear the voices like you do. So we have different perspectives. But it sounds very stressful.”

  •  Avoid the two extremes of:

Collusion (“You’re right. You are being followed.”)
Direct confrontation (“That is not true. Stop thinking that!”).

  • Try to distract your relative by talking about something else or suggest a distracting activity to get his/her mind off of his/her experience.
  • Sometimes it is best to just give him/her space.

Listen and Reflect: Often, just listening and reflecting what your relative is saying, especially in heated moments, is all that is needed to calm tensions and make him/her feel heard. Reflect back what he/she is saying in a nonjudgmental way (e.g., “what I hear you saying is that you’re frustrated that I don’t hear the voices and you get angry when I remind you about going to your psychiatrist appointments.”)

Check Your Own Thinking: Take a step back and check beliefs and assumptions such as, “He’s lazy,” “I shouldn’t have to remind him to pick up his clothes,” “I can’t ask her to do anything because she’s ill” “She can’t accomplish her goals because she has schizophrenia.” Are these thoughts completely true? Is there another interpretation (e.g. negative symptoms of schizophrenia)? Are these thoughts helpful?

Be Mindful of Likely Neurocognitive Problems: People with psychosis typically have problems with concentration, memory, and planning and organizing, which presents an added challenge. If necessary, try to adjust for these problems with repetition, verbal and visual reminders, short and simple communication, etc.

Insight: It may not be necessary for your relative to accept that he/she has schizophrenia. Unfortunately, schizophrenia is a heavily stigmatized disorder and many consumers reject it strongly. Although it may often be ideal for a person to accept their diagnosis, it is not necessarily required for recovery. Your relative may be more comfortable with other, less stigmatized explanations (e.g., “an overactive brain” or “oversensitivity to stress.”) As long as your relative recognizes the importance of medication, these explanations may be just fine. It is dangerous to push a person into insight by confronting them, because they may get depressed and have a higher risk of suicide.

Maintain Hope: Psychosis is stigmatized and consumers may encounter negative attitudes, even in their own doctors. It’s important to keep hope for recovery alive for your relative. Most likely they can sense if you do or don’t have hope. Having reasonable hopeful expectations for your relative can go a long way

Goals: Talk to your relative about what his/her goals are: a job, independent living, friends, boyfriend/girlfriend? Keep coming back to these goals; use them as “leverage” and remind your relative about them. This can help instill hope and unite everyone under a common purpose.

Positive Reinforcement: This is the most effective way to change and/or maintain someone’s behavior. Reward your relative for positive behaviors, even if just verbally. Avoid punishment and harsh criticism.

Example: “I’ve noticed that you’ve done half of your laundry; that’s great. You’re halfway there. This is a good step in the right direction of your goal of getting your own place someday.” Instead of: “Why did you only do half of your laundry? How will you ever live on your own if you can’t even finish your laundry?”

Stress Management: Stress triggers psychotic symptoms. People with psychosis are more reactive to stress, even from common everyday hassles. Both acute (sudden) stress and chronic (accumulating more gradually over time) stress can push a vulnerable person into psychosis. Therefore, it is important to reduce stress at home, for the consumer and also for the family, since the consumer responds to family’s stress as well. For example, don’t argue with other family members on how to deal with a problem (at least not in front of the consumer). Also, don’t over-sacrifice yourself. Your mental health is just as important. Just like oxygen masks in airplanes, you must take care of yourself in order to be able to care for your relative.

Do What Works: All of the above are guidelines. People with psychosis vary tremendously, so you may find certain techniques work better than others. For example, a consumer who has some insight into the possibility that their paranoid beliefs may be false may respond positively to family members reminding him/her of the facts and reality.

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