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Early Intervention in Psychosis ‘At Risk Mental States’ Cognitive Therapy for People at High-Risk 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

Framework of CT for ARMS • Cognitive therapy main intervention • However it can Framework of CT for ARMS • 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 • Develop therapeutic relationship • Assessment • Establish shared problem list • Intervention Process • 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 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 • Anxiety (French and Morrison, 2003) - Common Themes in EDIE 1 Problem Lists • Anxiety (French and Morrison, 2003) - 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 • • • “I am unhappy with where I live. ” “I feel Problems • • • “I am unhappy with where I live. ” “I feel anxious and paranoid when I leave the house. ” “I worry that people know what I’m thinking”. “I feel depressed. ” “I worry about people laughing at me when I go out. ” “I need to get a job. ” “I want more money. ” “I have difficulties expressing myself”. “I want to know what is wrong with me. ” “I need a girlfriend. ”

Goals • When I go out, I would like to be able to distinguish Goals • 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%). • To begin to understand if what I am experiencing is the start of psychosis. • To find out what alternative accommodation is available and contact various housing agencies in order to get on their waiting lists. • 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 • • Formulation Normalisation Working with metacognitive beliefs Generating possibilities for intrusions Intervention Strategies • • Formulation Normalisation Working with metacognitive beliefs Generating possibilities for intrusions Safety behaviours Selective attention Activity scheduling Relapse prevention

Formulation • The formulation using the intrusions model (Morrison 2001) is developed within sessions Formulation • 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 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 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 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 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 What happened Going out in public Day dreaming on the bus What I make of it Other 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 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 • This uses the existing body of work from Kingdon and Turkington (1994). Normalisation • 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 • The model of psychosis described directs treatment towards working with metacognition. • Metacognition • 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 • As with clients who have established psychotic symptoms generating possibilities Generating Alternative Explanations • 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 • • Advantages / disadvantages Exhaustive range of possible explanations Ø GENERATING ALTERNATIVE EXPLANATIONS • • Advantages / disadvantages Exhaustive range of possible explanations Ø • • Socratic dialogue Ø Being creative Belief ratings for each (0 -100%) with associated emotions Evidence for and against each one

ALTERNATIVE EXPLANATIONS: Case Example • • • Situation: I have been seeing things like ALTERNATIVE EXPLANATIONS: Case Example • • • 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 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 reduce • People with a brain tumour have strange experiences • I have bad headaches at times 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 • 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 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 • Look out for Insecure Paranoid Carry on as normal Reassured strange looks • Worry

Safety Behaviours • Safety behaviours in the maintenance of anxiety disorders have been extensively Safety Behaviours • 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 Interpretati on Safety Behaviour Saw people laughing whilst out Examples of Safety Behaviours Experience Interpretati on 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 I am going mad/ Hide head under

BEHAVIOURAL EXPERIMENT: Case example Thought to be tested: When I feel anxious other people 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 • This has been strongly implicated in our experience of working with Selective Attention • 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 • Frequently people are beginning to isolate themselves, reducing the frequency and Activity Scheduling • 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 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 • To increase awareness in primary care services, secondary care services, voluntary Our Approach • 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