Cognitive behavioural approaches to Cognitive behavioural approaches to the detection and prevention of the detection and prevention of

relapserelapse

Staying Well After Psychosis IIStaying Well After Psychosis II

Dr Andrew GumleyDr Andrew GumleySenior Lecturer in Clinical PsychologySenior Lecturer in Clinical Psychology

University of GlasgowUniversity of Glasgow&&

ESTEEM: GlasgowESTEEM: Glasgow

ScheduleSchedule 09-3009-30 Aims and ObjectivesAims and Objectives 09-45 09-45 Exercise I Rehearsal of Formulation Exercise I Rehearsal of Formulation 10-1510-15 FeedbackFeedback 10-3010-30 Coffee BreakCoffee Break 10-5010-50 Prioritising key problematic beliefs and behavioursPrioritising key problematic beliefs and behaviours 12-0012-00 Exercise II: Generating alternative strategiesExercise II: Generating alternative strategies 12-30 12-30 LunchLunch 13-3013-30 Compassionate mind versus rational mindCompassionate mind versus rational mind 13-45 13-45 Exercise III: Developing a behavioural experimentExercise III: Developing a behavioural experiment 14-1514-15 Coffee BreakCoffee Break 14-3514-35 Anticipating organisational / service barriers to relapse Anticipating organisational / service barriers to relapse

prevention interventionprevention intervention 15-1515-15 Planning and action pointsPlanning and action points 15-4515-45 Discussion and CloseDiscussion and Close

AimsAims This workshop builds directly the skills and themes This workshop builds directly the skills and themes

developed within Workshop 1. Participants will have the developed within Workshop 1. Participants will have the opportunity to rehearse, revise and / or develop high level opportunity to rehearse, revise and / or develop high level skills in formulation based cognitive behavioural strategies skills in formulation based cognitive behavioural strategies aimed at recovery and staying well after psychosis. By the aimed at recovery and staying well after psychosis. By the end of the workshop participants will practice skills inend of the workshop participants will practice skills in– developing a personal narrative incorporating clients’ developing a personal narrative incorporating clients’

experience of psychosis,experience of psychosis,– use clients’ narrative to support them in exploring key use clients’ narrative to support them in exploring key

personal themes concerning loss, humiliation, entrapment, personal themes concerning loss, humiliation, entrapment, fear, threat and shame, fear, threat and shame,

– understand how service and staff interpersonal responses understand how service and staff interpersonal responses might alleviate or intensify clients cognitive, emotional and might alleviate or intensify clients cognitive, emotional and behavioural reactions to psychosis,behavioural reactions to psychosis,

– rehearse cognitive behavioural strategies aims at transforming rehearse cognitive behavioural strategies aims at transforming such personal meanings, andsuch personal meanings, and

– conceptualise systemic interventions aimed at transforming conceptualise systemic interventions aimed at transforming problematic service responses to signs of elevated relapse risk.problematic service responses to signs of elevated relapse risk.

Workshop methodologyWorkshop methodology

Modelling therapeutic processModelling therapeutic process Where possible, exercises conducted Where possible, exercises conducted

within clinical teams to aid within clinical teams to aid dissemination.dissemination.

Exercises are designed to specifically Exercises are designed to specifically target clinically relevant material.target clinically relevant material.

Feedback on needs and strengths of Feedback on needs and strengths of specific exercises.specific exercises.

Therapy scenarioTherapy scenario Th:Th: What do you make of your voices?What do you make of your voices? Pt:Pt: They’re aliens, they tell me I’m a paedophile, They’re aliens, they tell me I’m a paedophile,

an an abuser, its horrific………abuser, its horrific……… Th: Th: What does your doctor make of these voices, What does your doctor make of these voices,

what does he think they are caused by?what does he think they are caused by? Pt:Pt: [Pause] He thinks I’ve got schizophrenia.[Pause] He thinks I’ve got schizophrenia. Th:Th: What do you think about that?What do you think about that? Pt:Pt: It can’t be true. That would mean I have an It can’t be true. That would mean I have an

illness, and that would mean these voices illness, and that would mean these voices come come from me……..[Pause] Those things couldn’t from me……..[Pause] Those things couldn’t

come out of my head.come out of my head.

Attributions

“Jimmy doesn’t get up cos he’s just being lazy”

Expressed Emotion

Criticism and hostility

Psychophysiological arousal

Positive Symptoms

Internal, Personal,

stable attribution

Relapse and readmission

Negative self evaluation

Exercise IExercise I

TeamsTeams Choose patient / client from TuesdayChoose patient / client from Tuesday Rehearse formulationRehearse formulation

– Interpersonal contextInterpersonal contextFamily and team attributions / responsesFamily and team attributions / responses

– BeliefsBeliefs– EmotionsEmotions– Cognitive behavioural strategiesCognitive behavioural strategies

Cognitive Interview for Early SignsCognitive Interview for Early Signs

Establish last episode (or most Establish last episode (or most memorable)memorable)

Identify key eventsIdentify key events Prioritise events according to significance Prioritise events according to significance

to individualto individual Elicit associated memories, images and Elicit associated memories, images and

other cognitionsother cognitions Establish meaning linked to self and self in Establish meaning linked to self and self in

relation to illnessrelation to illness Link event and meaning to cognitive, Link event and meaning to cognitive,

perceptual and physiological experienceperceptual and physiological experience

Time frameTime frame ESTABLISH DATE OF LAST RELAPSEESTABLISH DATE OF LAST RELAPSE ESTABLISH ONSET OF PRODROMEESTABLISH ONSET OF PRODROME CHOOSE EVENT DURING PERIOD BETWEEN CHOOSE EVENT DURING PERIOD BETWEEN

ONSET OF PRODROME AND RELAPSEONSET OF PRODROME AND RELAPSE– Prototypic questions: Prototypic questions: – When talking about your last relapse is there a When talking about your last relapse is there a

particular memory that comes to mind?particular memory that comes to mind? – At what point did this occur?At what point did this occur?– Are their other events which come to mind?Are their other events which come to mind?

ESTABLISH TIME LINE FOR EVENTS IN RELATION ESTABLISH TIME LINE FOR EVENTS IN RELATION TO ONSET OF PRODROME AND RELAPSETO ONSET OF PRODROME AND RELAPSE

Hot CognitionsHot Cognitions ESTABLISH EVENT ASSOCIATED WITH ‘HOT’ COGNITIONSESTABLISH EVENT ASSOCIATED WITH ‘HOT’ COGNITIONS

– Prototypic questions:Prototypic questions:– Which of these events distresses you most?Which of these events distresses you most?– If only one of these events occurred which would have been If only one of these events occurred which would have been

the most upsetting?the most upsetting?– Why is that?Why is that?

ELICIT MEMORIES AND IMAGES ASSOCIATED WITH THE ELICIT MEMORIES AND IMAGES ASSOCIATED WITH THE EVENT?EVENT?– Prototypic questions?Prototypic questions?– What was so upsetting about that?What was so upsetting about that?– Are there thoughts and images which come to mind?Are there thoughts and images which come to mind?– Can you describe these?Can you describe these?

GUIDED DISCOVERY TO ESTABLISH MEANINGGUIDED DISCOVERY TO ESTABLISH MEANING– What does that event mean to you?What does that event mean to you?– What was the worst thing about that?What was the worst thing about that?

LinkageLinkage ELICIT COGNITIONS RELATED TO SELF, AND SELF ELICIT COGNITIONS RELATED TO SELF, AND SELF

IN RELATION TO ILLNESSIN RELATION TO ILLNESS– What does it say about your illness?What does it say about your illness?– Do you still think that?Do you still think that?– How does it make you feel about your illness?How does it make you feel about your illness?

LINK EVENT AND MEANING THROUGH COGNITIVE, LINK EVENT AND MEANING THROUGH COGNITIVE, PERCEPTUAL, AND PHYSIOLOGICAL EXPERIENCEPERCEPTUAL, AND PHYSIOLOGICAL EXPERIENCE– When you think about that now how do you feel? (probe When you think about that now how do you feel? (probe

cognitive, perceptual and physical experience?cognitive, perceptual and physical experience?– What do / did you notice about your thoughts?What do / did you notice about your thoughts?– What do/ did you notice about your body?What do/ did you notice about your body?

FORMULATE AND SUMMARIZE BY LINKING EVENT, FORMULATE AND SUMMARIZE BY LINKING EVENT, INTERNAL EXPERIENCES, BELIEFS AND INTERNAL EXPERIENCES, BELIEFS AND EMOTIONAL/ BEHAVIOURAL SEQUELAEEMOTIONAL/ BEHAVIOURAL SEQUELAE

Therapist TasksTherapist Tasks

Identify key cognitionsIdentify key cognitions Identify key setting eventsIdentify key setting events Identify key behavioural strategiesIdentify key behavioural strategies

Prioritise in relation to Prioritise in relation to – Emotional temperatureEmotional temperature– Interpersonal impactInterpersonal impact– Day to day impactDay to day impact

Problematic Experiences

Attachments, loss, psychosis etc

Core Beliefs

E.g. I am useless, Others are dangerous

Overdeveloped Behaviours

Aggressiveness, suspiciousness, self punitiveness

Underdeveloped Behaviours

Self care and nurturance, affiliation, assertiveness

Pivotal AssumptionsPivotal Assumptions

Related to relapse, adjustment and Related to relapse, adjustment and recoveryrecovery

Capture experiential meanings linked to Capture experiential meanings linked to psychosis and premorbid experiencespsychosis and premorbid experiences

Assimilation and (over)accommodationAssimilation and (over)accommodation Strongly linked to emotion and “hot” Strongly linked to emotion and “hot”

cognitioncognition Linked to strategic deployment of Linked to strategic deployment of

behavioural strategiesbehavioural strategies

ExamplesExamples If I relapse then my family will be disappointedIf I relapse then my family will be disappointed If people know how I feel then they will laugh at If people know how I feel then they will laugh at

meme If I get stressed then I will get unwellIf I get stressed then I will get unwell If I do not have complete control of my thoughts If I do not have complete control of my thoughts

then I am defectivethen I am defective If I seek help then I will be admittedIf I seek help then I will be admitted If I show any signs of weakness then they will put If I show any signs of weakness then they will put

me in hospitalme in hospital If I get upset this means I am weak and needyIf I get upset this means I am weak and needy

Exercise IIExercise II

PrioritisePrioritise– One key belief and associated recurring One key belief and associated recurring

behaviourbehaviour– Consider carefully the linked associated Consider carefully the linked associated

valued goals and benefits linked to that valued goals and benefits linked to that belief and recurring behaviourbelief and recurring behaviour

– Identify an alternative behaviour that Identify an alternative behaviour that would achieve person’s valued goal would achieve person’s valued goal without same degree of costs.without same degree of costs.

Rational MindRational Mind Looks at the evidenceLooks at the evidence Is scientific, treats thoughts and ideas as theories Is scientific, treats thoughts and ideas as theories

to be disconfirmedto be disconfirmed Likes to have several alternatives to choose fromLikes to have several alternatives to choose from Likes to test things and run experimentsLikes to test things and run experiments Does not like to be hastyDoes not like to be hasty Knows that knowledge develops slowlyKnows that knowledge develops slowly Learns from trial and errorLearns from trial and error Weighs advantages and disadvantagesWeighs advantages and disadvantages Takes a long term viewTakes a long term view

Compassionate mindCompassionate mind Has empathy and sympathyHas empathy and sympathy Is concerned with growth and reaching Is concerned with growth and reaching

potentialpotential Is concerned with supporting, healing and Is concerned with supporting, healing and

listeninglistening Is kind and friendlyIs kind and friendly Is quick to forgive and slow to condemnIs quick to forgive and slow to condemn Does not attack but repairsDoes not attack but repairs Recognises and accepts imperfectionRecognises and accepts imperfection Self worth and self acceptance ore not Self worth and self acceptance ore not

earned but are unconditionalearned but are unconditional

Behavioural experimentsBehavioural experiments

Focus on target thought and explore Focus on target thought and explore evidence.evidence.

Identify stimuli and behavioursIdentify stimuli and behaviours Identify alternative beliefIdentify alternative belief Present rationale for experimentPresent rationale for experiment Conduct experimentConduct experiment Discuss results in terms of Discuss results in terms of

formulationformulation

Specific proceduresSpecific procedures Identify key target beliefIdentify key target belief

– E.g. I am an okay personE.g. I am an okay person Operationalise cognitionOperationalise cognition

– People are friendly towards mePeople are friendly towards me– People smile at mePeople smile at me– They use eye contact with meThey use eye contact with me

Alternative behaviour to strengthen new beliefAlternative behaviour to strengthen new belief– Giving eye contact to others, smiling etcGiving eye contact to others, smiling etc

Develop a testable prediction.Develop a testable prediction.– Go into Safeway, at meat counter smile, say hello.Go into Safeway, at meat counter smile, say hello.

Consider what can go wrongConsider what can go wrong– Person ignores mePerson ignores me– They start laughingThey start laughing

Exercise IIIExercise III

Developing and planning a Developing and planning a behavioural experimentbehavioural experiment– Identify key target beliefIdentify key target belief– Operationalise beliefOperationalise belief– Alternative behaviour to strengthen new Alternative behaviour to strengthen new

beliefbelief– Develop a testable prediction. Develop a testable prediction. – What can go wrong.What can go wrong.

INTRUSIONSImages of being naked

Sexual IntercourseBodily hair

SITUATIONSocial situations

METACOGNITIVE APPRAISALI’m mixed up

I’m mentally illThe devil is implanting thoughts in my head

SAFETY BEHAVIOURSAvoidance, Rumination,

Vigilance

EMOTIONSDisgust, Shame, Fear,

Depression

PHYSIOLOGYTension

AssessmentAssessment

Anxious Thoughts InventoryAnxious Thoughts Inventory Metacognitions QuestionnaireMetacognitions Questionnaire Collaboratively developed Collaboratively developed

assessment:assessment:– Frequency of Intrusions (0-10)Frequency of Intrusions (0-10)– Intrusiveness (0-10)Intrusiveness (0-10)– Dwelling (0-10)Dwelling (0-10)– Belief “I am mentally Ill” (0-10)Belief “I am mentally Ill” (0-10)– Dsitress (0-10)Dsitress (0-10)

QuestionsQuestions

What thought would you focus on?What thought would you focus on? How would you explore the thought?How would you explore the thought? What behaviour would you focus on?What behaviour would you focus on? How is behaviour linked to thought?How is behaviour linked to thought? What alternative belief could you test out?What alternative belief could you test out? What could you set up with the patient to What could you set up with the patient to

test out the alternative belief?test out the alternative belief? What are your predictions for this test?What are your predictions for this test?

Frequency of IntrusionsFrequency of Intrusions

Frequency

02468

10

1 7 13 19 25 31 37 43 49 55

Days

Frequency

Frequency

IntrusivenessIntrusiveness

Intusiveness

02468

1012

1 7

13 19 25 31 37 43 49 55

Days

Intrusiveness

Intusiveness

DwellingDwelling

Dwelling

0

2

4

6

8

1 7

13 19 25 31 37 43 49 55

Days

Dwelling

Dwelling

BeliefBelief

Belief

0

5

10

15

1 7

13 19 25 31 37 43 49 55

Days

Belief

Belief

DistressDistress

Distress

0

5

10

1 7

13 19 25 31 37 43 49 55

Days

Distress

Distress

Pre / Post AssessmentPre / Post Assessment

AnTIAnTI– Social = 28Social = 28– Health = 14Health = 14– Meta = 23Meta = 23

MCQMCQ– Positive = 29Positive = 29– Control = 48Control = 48– Efficiency = 18Efficiency = 18– Negative = 28Negative = 28– Self Consciousness = Self Consciousness =

2525

AnTIAnTI– Social = 10Social = 10– Health = 7Health = 7– Meta = 8Meta = 8

MCQMCQ– Positive = 29Positive = 29– Control = 20Control = 20– Efficiency = 10Efficiency = 10– Negative = 17Negative = 17– Self Consciousness = Self Consciousness =

1717

Contact:Contact:

a.gumley@clinmed.gla.ac.uka.gumley@clinmed.gla.ac.uk