NHS Foundation TrustSurrey and Borders PartnershipAdapting CBT for psychosis:

creative ways with cognitive impairments

Authors: Sophie Holmes* (Chartered Consultant Clinical Psychologist and Trust Lead for Psychosis) Rowena Rossiter, Jo Jennison*, Julie Nixon (Chartered Clinical Psychologists Learning Disabilities) (*= current employees)

Working with cognitive impairment why does it matter to me? There are many types of cognitive impairments including:

Cognitive impairments associated with psychosis: - Reasoning biases (e.g. jump to conclusions) - Attention and working memory problems - Negative symptoms

Lowered expectations from long-term mental health, learning difficulties and associated care

Medication effects

Specific learning difficulties/learning disabilities

Pervasive developmental disorders Autistic Spectrum Disorders, Aspergers Syndrome

Neurological disorders epilepsy, stroke, head injury, ADHD, dementia

Impairments associated with ageing and demographic changes increasing older adult population

Adaptations of CBT for working with cognitive impairments may also assist where: - English is not first language - Sensory impairments - A picture is worth a thousand words

Many cognitive impairments are undiagnosed in the general population (Simoneff et. al, 2006). When cognitive impairments are diagnosed (e.g. learning disabilities), mental health problems often go undetected and untreated for a range of reasons including lack of awareness, gaps in service provision and diagnostic overshadowing (Hatton 2002).

Demands of current legislation and policy (Disability Discrimination Act, NICE, Improving Access to Psychological Therapy (IAPT), No Health Without Mental Health) require psychological services to be accessible to all.

Introduction We aim to show: Why working with cognitive impairments matters Three cases illustrating practical adaptations for people

with cognitive impairments and psychosis drawing on published practice-based evidence.

What practice-based evidence did we draw on and what did we do? We drew on literature on:

General adaptations of CBT for people with cognitive impairments /young developmental levels; and Specific CBT for people with psychosis who may also have cognitive impairments/young developmental levels

CBT Studies - General CBT Studies - PsychosisLearning Disabilities Sternfert-Kroese (1997) Leggett (1997) SABP Guidance on CBT Kirkland (1995) and people with LD (2004, 2007) Haddock et al (2006) Leggett (1997) Favrod et al (2007) Barrowcliff (2008)Pervasive Attwood (2004) Developmental Hare and Paine (1997) Disorders (e.g. ASD)

Children and Stallard (2002) Collerton et al (2004) Young People Wragg and Whitehead (2004)

Ageing Laidlaw et al (2004) Charlesworth et al (2004) Coon et al (2004) Walker (2004)

The literature has shown CBT can be effective for anxiety, trauma, depression with children as young as four years, people with learning disabilities and adults with dementia if highly visual concrete materials are used and concepts simplified. More recent studies show how these adaptations enable CBT to be used with those with young developmental levels/cognitive impairments and psychosis.

Implications/ Practice issues You can do it! Individualise assessment and

intervention with visual, concrete materials

Plan for shorter but, maybe, more sessions; plan carefully for generalisation and maintenance

Labelling challenges thoughts or voices; memories or hallucinations; PTSD; abuse

Hopelessness associated with diagnosis

Training and supervision use/create networks e.g. our Trust developed a CBT and psychosis peer supervision/network across Children and Young People, Working Age Adult and Learning Disability services. Allows cross-fertilisation of ideas and

resources, and resource development (e.g. guidance on CBT/ LD/ psychosis)

More work with/through carers (share CBT formulation, consider contextual/systemic issues, CBT for carers depression/anxiety etc)

Consider broader training issues to meet demands of NICE compliance, IAPT , Draft BABCP Core Curriculum, consider adapting CBT and cognitive impairment as mainstream core competence

References and a handout are available from: Sophie.Holmes@sabp.nhs.uk

Case examples illustrating practical adaptations for people with cognitive impairments and psychosis:(Based on clinical work with changes to ensure anonymity)

David (66)AIM CBT strategies to help manage the voices he currently hears

BACKGROUND Moderate learning disability, hospitalised aged 17 for 3 years (immigrated to UK with family when

8 years)

Diagnosed with paranoid schizophrenia, has sibling with same diagnosis

Returned to family, then to residential care (further periods in hospital, long term medication)

James and the Dog 1. James doesnt like dogs

How does he feel?

2. James is scared

What does he think when hes scared?

3. What does James do?

Davids Assessment Use of visuals (line drawings and photographs) to assess naming and understanding of feelings; James and the dog for Think-Feel-Do links, (see below); staff interviews; file search (including

previous psychology involvement re sexuality issues consent, possible abuse in teenage years, sex education group); diaries for voices and activities; anger thermometer: depression rating.

CBT/LD/Psychosis example of personalised psychoeducation/ therapy worksheet

Davids Intervention Main elements: Psychoeducation around source and origin

of voices

Normalisation of experiences and illness

Development of distraction techniques (naming objects in the room, physical exercise and sub vocal speech/singing)

Behavioural experiments explore concept of control over the voices bringing on the voices and turning them off

Explore cultural issues voices often contain racial comments

Further explore triggers for voices

Relaxation strategies practiced in sessions, audiotape was made for home use, prompt sheet for calming/distracting activities (see below)

Personalised coping book developed from above, shared with staff at Davids residential home

Outcomes for David Staff and self report measured through self report, staff report, diary and a quiz show David as:

Less anxious, having less intrusive/distressing experiences and less medication

Successfully utilising a number of above strategies

More knowledgeable about his experiences and symptoms

Having more friends and activities, and an improved quality of life

Jenny (28)AIM Understand and formulate experiences, plan interventions, including CBT, to reduce voices, self harm and aggression

BACKGROUND Abusive childhood, borderline learning disabilities plus specific learning difficulties

Admitted to hospital from court having attempted to rob bank with knife as potential weapon because of voices. Already diagnosed as paranoid schizophrenic.

Aggression to people and property, withdrawal, self-harm

Voices tell her to harm herself, harm others and negative content (3rd and 1st person youre sh*t, Im rubbish).

Jennys Assessment Use of visuals for Think-Feel-Do; body map; how you feel; thought bubbles; form for feelings, situations and thoughts (see right).

Jennys Intervention Main elements:

Psychoeducation around emotions, thoughts-feelings-behaviour links, the source and origin of the voices she hears (some voices as memories/thoughts)

Link to/ listen to/believe story of childhood backed-up by other sources

Normalisation of physical, emotional, behavioural and cognitive experiences (general and specific trauma memories)

Visual formulation (Kirklands 2005 diagrammatic ABC formulation framework)

Exploring evidence for thoughts and thinking traps or errors, developing alternative explanations and coping thoughts

Self-calming strategies including different approaches to relaxation, use of music (recording personalised selections for self calming, feeling happier, getting motivated)

Development of personalised coping books from above Miss Cant and Miss Can and Miss Frazzle and Miss Calm using clients own artwork and personally generated guardian angel cartoon characters (see right)

Identify prevention techniques keeping busy, going to talk to staff if she experiences warning signs, using relaxation, music, singing, physical exercise, looking at the coping books

Behavioural experiments to trial control over voices/thoughts practicing bringing them on and turning them down or off

Staff involvement in supporting assessment, formulation, planning and trialling interventions and maintaining effective ones

Outcomes for Jenny Staff and self report measured through diary and mood, thought, activity monitoring show Jenny as:

Experiencing less voices/hallucinations/anxiety

Receiving less medication

Increased engagement in therapy/ ward life

Moved to supported adult placement and began apprenticeship

Sam (16)AIM CBT strategies to help manage anxiety and distressing dreams/ visual and auditory hallucinations; develop social and community skills and self esteem

BACKGROUND Mixed race, mild Learning Disability (LD), Autism Spectrum Disorder (ASD)

Domestic violence and abuse in childhood; mother, Sam and brother moved to new area for their safety when Sam was 8 years (away from extended family and social support), death of great grandmother with whom he had good relationship

Mother has long-standing difficulties arisi