Psychological therapy in early psychosis

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Psychological therapy in early psychosis

• David Fowler
• Reader in Clinical Psychology, UEA
• Consultant Clinical Psychologist, NMHCT

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What I will talk about

• What is CBT for psychosis and are there different
  types of CBT?
• Do we need different therapies for different
  phases of early psychosis?
• The case for the use of specific psychological
  interventions and current research

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Acknowledgements

• Norfolk Early Intervention service colleagues Dr
  Iain Macmillan, Nick Bishop, Mark Wright, Peter
  Edge, Ruth Lin, Jane Wallace...and new....,
• UEA colleagues and Doctoral students Mike Day,
  Claire Harrison, Sam Vaughan, James Plaistow
• PRP (Welcome Trust programme grant) colleagues
• Philippa Garety, Elizabeth Kuipers, Paul
  Bebbington, Graham Dunn, Rebbecca Rollinson et
  al...

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Young people with early psychosis

• Have episodes of severe disturbances in thought,
  emotion and behaviour (delusions and
  hallucinations)
• Most recover from such episodes but some remain
  socially disabled and depressed
• Some are at high risk of developing chronic
  syndromes with need for repeated hospitalisation
  and high service use
• need specialised multidisciplinary care due to
  the complexity of their problems and difficult
  to treat presentations

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Ben
Ben came into contact with mental health services
because his mother was worried about him. He had
recently left home to live in a bed-sit. He had
become increasingly disorganized. His flat walls
were covered in paintings and he was pre-occupied
with drawing, not sleeping and not eating or
looking after himself. He talked in a bizarre way
about God, good and evil and about how his task
was to save the world. He said that painting
helped him to make sense of things. He was
clearly listening to voices. He said these were
God and the Devil talking to him. He said he
didn't need any help.
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A psychological perspective

• Psychosis as a life crisis which sets a series
  of adaptive demands for the individual

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Making sense of psychosis formulating psychotic
problems

• Normal models of adaptation to stress
• Vulnerability stress models
• Cognitive models of psychotic symptoms

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The evolution of voices and delusional beliefs
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The cognitive model of psychosis and its clinical
implications

• The cognitive perspective suggests that psychosis
  is more amenable to understanding than is
  commonly believed
• Helping people understand the nature of their
  personal vulnerability to psychosis is a core
  process of cognitive therapy
• Cognitive therapy involves helping people to
  become aware of errors in the way they think
  about psychotic experience to compensate for
  these
• The aim is to help the person construct a less
  distressing and more adaptive way of
  understanding their predicament

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Cognitive Behaviour Therapy

• Works from the patients point of view
• Is collaborative
• Builds up strengths
• (does not strip away defences)
• Builds on good basic psychotherapeutic skills
  (warmth, empathy, concern)
• Central task is making sense of and explaining
  psychosis
• Process of therapy, strategy and use of
  techniques is guided by individualised assessment
  and formulation

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The six stages of Cognitive Behaviour Therapy for
Psychosis
Engagement and assessment Promoting self
regulation of psychotic symptoms Developing a
shared model of psychosis Addressing delusions
and beliefs about voices Addressing
dysfunctional assumptions about self and
others Addressing social disability and risk of
relapse
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Adaptations in working with people with
persistent voices and delusions

• People with high conviction in delusions
  typically lack of a shared rationale with
  therapists
• People with voices typically do not regard them
  as symptoms
• Overcoming dissonance and working from the
  patients perspective is key
• Flexibility, individualisation, and careful
  attention to engagement is required

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Engagement
Assessment
Narrative Work
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Engagement
Assessment
Formulation
Schema work
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Engagement
Formulation
Strategies
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Engagement
Formulation
Strategies
Relapse prevention Interventions
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CBT for psychosis?
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CBT for psychosis a better analogy
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Does CBT work?Published trials with people with
treatment resistant psychosis

• 
  Effect size
• London-East Anglia trial CBT versus case
  management 0.86
• (Kuipers, Fowler, Garety et al, Brit. J
  Psychiatry,1997 1998)
• (9 months individually formulated CBT)
• 29 improvement in BPRS symptom ratings
• 65 CBT versus 17 CM made 25 improvement in
  symptoms
• Manchester trial CBT versus supportive
  counselling 0.57
• (Tarrier et al BMJ 1998 Brit. J
  Psychiatry,1999)
• (8 weeks, CBT package techniques)
• Wellcome trial CBT versus befriending
  1.18
• (Sensky, Turkington, Kingdom et al, Arch.Gen,
  Psych 2000)
• (9 months individually formulated CBT)
• .

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Systematic review of trials of CBT (odds
ratio)Participants receiving CBT have a 22
greater chance of making a 50 improvement in
mental state at post treatment than alternative
condition
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RCT of CBT to prevent relapseThe PRP project

• Sample People with psychosis presenting with
  second or subsequent acute psychotic relapse in 5
  centres in London, Essex and Norfolk
• Design 1) Alone CBT vs TAU n280
• 2) Family CBT vs FI vs TAU n90
• 9 months treatment, 2 year f/u
• Measures
• 1) relapse, readmission, cost
• 2) symptoms, social functioning, quality
  of life
• 3) process measures
• Recruitment at 11/03 n212

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CBT in relapse prevention (Gumley et al, 2003)

• Targeted at high risk of relapse groups
• Therapy initiated at recovery traditional CBT
  approach (psychoeducation, warning signs,
  management of relapse, fear of relapse)
• Booster sessions at incipient relapse
• At 12-months, 11 (15.3) CBT group 19 (26.4) TAU
  admitted
• 13 (18.1) CBT relapsed compared to 25 (34.7) in
  TAU
• CBT group showed greater improvement in negative
  symptoms (mean difference CBT - TAU in change
  from baseline at 12 months -1.73, p 0.035, 95
  CI 3.33, -0.13), global psychopathology (-4.10,
  p 0.0012, 95 CI 6.55, -1.65), performance of
  independent functions (2.70, p 0.027, 95 CI
  0.32, 5.08) and prosocial activities (3.99, p
  0.0072, 95 CI 1.10, 6.88).
• (Rector and Beck, 2003, Schiz, Res., Sensky et
  al, 2001 also show benefits in negative
  symptoms, gen psychopathology from traditional
  CBT approach)

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Conclusions

• There is strong evidence for effects of CBT on
  symptom reduction and distress with people who
  have distressing chronic treatment resistant
  psychotic symptoms
• There are promising indications of evidence for
  CBT in preventing relapse/readmission the PRP
  study will provide a definitive indication

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What interventions for what stage of early
psychosis ?

• At risk mental states - anomalous experiences.
  odd beliefs, distress
• First Episode - severe disturbances of thought,
  behaviour and affect
• Recovery - amotivation, depression, withdrawal
• First admission- psychosis and the effects
  hospitalisation
• Second episode and relapse
• Delayed recovery/ongoing psychosis-treatment
  resistant symptoms, relapse, chronic emotional
  disturbance and social disability

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The evidence basis for specific psychosocial
interventions at different stages

• At Risk Mental States 2 preliminary trials of
  CBT further trials underway/planned
• First Episode equivocal evidence for CBT-large
  trial (SoCRATES) suggests support CBT
• Social recovery and depression No trials-need
  for a new treatment (evidence for supported
  employment (IPS) in chronic cases, preliminary
  evidence for CBT on depression/negative symptoms)
• Relapse good preliminary evidence PRP trial
  will be definitive
• Delayed recovery and treatment resistant
  psychosis evidence is strong, NICE suggest CBT
  should be provided

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Problems in At Risk Mental States

• Something odd is going on I feel strange
• I feel different from others I sense evil
  around
• Anomalous experiences
• Search for meaning and delusional formation
• Ongoing psychological difficulties
• Engagement problems
• Drug abuse

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Therapy targets for early stage psychosis

• Establishing a relationship
• Providing a framework for understanding anomalies
  of experience
• Decatastrophising and normalising
• assisting the search for meaning
• managing ongoing psychological problems
  (anxiety/depression)
• Promoting adaptive behaviour by behave expts
• Structured short term therapy akin to traditional
  CBT for anxiety/depression

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Problems at the recovery stage

• I still feel ill Somethings wrong with me
• Im not quite right I feel different to
  before
• I'm fine I'm ok dont want help just want
  to get on with my life
• Amotivation
• depression
• social withdrawal and social disability
• anomalies of experience and beliefs
• NB These problems are often missed in people who
  may be described as doing ok

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Outcomes at 2 years First admission psychosis
cohorts in Norfolk (no EI service)

• Measures CAN, HoNoS, GAF, Health records
• Cohort 96/97 98/99
• No. 77 61
• Complete recovery (no relapse) 22 17
• Mod/severe ongoing psychosis 9 37/9
• Mod/severe Depression 60/28 55/31
• Number of unmet needs 5 5
• Mean GAF 58 63
• None/ meaningful activity 60/15 66/16

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The Issues

• Suicide occurs in 10-15 of casesmainly
• in first 5 years .
• Parasuicidal risk averages 20-30
• Rate of post psychotic depression in
  first-episodes 25-80

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Depression as a psychological reaction to
psychosis and trauma recent psychological studies

• Depression in early psychosis is associated with
  increased loss shame humiliation and entrapment
  and lower social comparison (Iqbal et al, 2001
  Plaistow and Fowler, submitted)
• Depression, negative symptoms and social
  disability are strongly associated with each
  other at the recovery stage and also with the
  degree to which individuals can see themselves in
  meaningful roles and goals in the future (Day and
  Fowler, Submitted)
• Depression is associated with reporting intrusive
  memories and avoidance of traumatic events
  (Fowler et al, In Press)

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So, what does all this mean for early
intervention??

• Amongst cases apparently symptomatically stable
  (in between psychotic episodes)
• we need to monitor and target depression and
  hopelessness, and prevent appraisals of loss
  shame and entrapment
• We need to carefully target patterns of social
  avoidance which may emerge initially as
  protective

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Individual placement and support

• Vocational workers focussing on social recovery
  who have links to employers and knowledge of
  employment issues work alongside case managers as
  part of an assertive outreach team (Bond)
• Hartford study (Mueser et al, J.Cons Clin
  Psychol, In Press) IPS (373 days employed) vs 176
  days standard treatment
• Crowther et al BMJ, 2001 systematic review

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Developing Individual Placement and Support

• Effects are on low paid service sector employment
  which is transitive
• Needs attention to meaningful goals and career
  pathways
• At present suitable for people who are fully
  recovered ready to work
• Can psychological therapy prepare more people for
  IPS?
• Factors involved include hopelessness,
  amotivation, cognitive deficits and depression

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The case for Social Recovery oriented CBT in
early psychosis

• We need a new treatment which offers social
  opportunities while addressing psychological
  problems including depression, social avoidance
• Ideally this will combine best practice in
  vocational interventions (IPS) with structured
  psychological interventions (CBT)
• This treatment is in the early stages of
  development

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Key psychosocial interventions in Early
intervention in psychosis to include

• Support through the acute phase in least
  restrictive supportive therapeutic settings
• CBT for delayed recovery treatment resistant
  psychosis and relapse
• Social recovery intervention Case managers
  providing an assertive vocational recovery
  programme addressing depression and anxiety in
  collaboration with supported employment/education/
  leisure.
• User and family support and psyched groups
• Family work
• With protocol driven psychopharmacology

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And it should all lead to.....

• a much better social and symptomatic long term
  outcome for young people with severe mental
  illness