DAY 1 FOURTH SESSION: NEGATIVE SYMPTOMS

ADHERENCE

RELAPSE PREVENTION

SELF CARE

Content Activity

Negative Symptoms Video Check (Funny Animals)

Adherence Pat Deegan Video

Relapse Prevention

Self Care

Closoure

WORKING WITH NEGATIVE SYMPTOMS

Section 10: Working with negative symptoms

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22

Environment

Symptoms Treatment TargetSocial Isolation

Absence of stimulationIncrease social supports and activities

Trauma & PTSDEmotional numbing and avoidance

Use Trauma Focused CBT to address the trauma

Social anxietySocial withdrawal

Identify the anxiety symptomsUse Behavioral Activation

NEGATIVE SYMPTOMS AND…

First Steps

Go back to the case formulation and find factors that may contribute to negative symptoms

Behavioral Activation and Behavioral Scheduling is an important

The following 3 slides are taken from: Tully, L.M. (PowerPoint presentation that also cited Ellis et al. 2013; Morrison et al. 2004) UCDavis.https://behavioralhealth.ucdavis.edu/sites/g/files/dgvnsk2356/files/events/slides-symposium/slides-psychosis-12-13-17/tully-121317.pdf

333

NEGATIVE SYMPTOMS AND…

Depression

Symptoms Treatment Targets

Possible relationship between self defeating beliefs and negative symptoms

Activity scheduleMastery and pleasure ratingsThe 3Cs to address cognitive distortions

Self Efficacy

Symptoms Treatment Targets

Possible relationship between self defeating beliefs and negative symptoms

Activity scheduleMastery and pleasure ratingsThe 3Cs to address cognitive distortions

444

Anxiety

Symptoms Treatment Targets

AvoidanceNumbing

Review formulation to identify triggers and maintenance processes

Use CBTp to target maintenance processes

Safety Behaviors

Symptoms Treatment TargetsMay be related to delusional thinking

Pros and cons of the behavior

Avoidance of traumatic triggers or even treatment interventions

Graded down behavioral experiments to test predictions

NEGATIVE SYMPTOMS AND…

555

HOW TO TEACH THE CLIENT ABOUT

NEGATIVE SYMPTOMS

• Make it safe, no judgments

• If the client is willing to discuss

– Acknowledge that they have been through a lot and that these experience can be exhausting. Makes sense to go slow

– Explain that many factors can lead to low energy and inactivity and that there are things they can do and ways to regain their life

• Let them know that recovery is in small steps

• Remind them that recovery happens!

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REVIEW OF NEGATIVE SYMPTOMS“behaviors are the ones that may be taken away from your relative as the illness takes

hold” Randye Kaye

• Cognitive Model- “Defeatist” beliefs (Grant & Beck, 2009)

– Low expectancies for pleasure

– Low expectancies for success

– Low expectancies owing to stigma

– Perception of limited resources- conscious and strategic attempts to limit re-injury

• Belief- Better not to try than to try and fail

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WHAT WE UNDERSTAND ABOUT NEGATIVE SYMPTOMS

• Neuro-cognitive deficits (attention, memory)

• Natural tendency to “shut down” to self-protect

• While the person may appear flat and emotionless

– Person may be overwhelmed by experiences

– Person may struggle with emotion regulation (tend to suppress and avoid)

– Person may have developed beliefs which interfere with action

• Common (inaccurate or unhelpful) explanations

– Lazy

– Just doesn’t care; gave up

888

VIDEO CHECK

About to watch a short didactic video behavior activation

0= won’t like it at all, will not be enjoyable

10= will love it, will be very enjoyable

https://www.youtube.com/watch?v=EtH9Yllzjcc

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PREMISE OF BEHAVIOR ACTIVATION

• Negative symptoms can lead to

…reduced interest in and ability to experience positive reward from the environment

…activity feels like effort, and a burden, why bother?

• By avoiding effort… experience relief of burden and avoid failing, which leads to more avoidance

• However, less activity= less chances for rewards

101010

WALKING THRU THE PROCESS

STEP 1: EXPLAIN HOW IT WORKS

• Step 1: Explain Behavioral Activation

– How stress/symptoms lowers energy and mood and interest

– How pulling away from things can reinforce the low energy and lack of interest

– The value of building in rewarding activities

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STEP 2: ACTIVITY MONITOR

• Step 2: Activity monitor- what do my days look like

– Rate Accomplishment, Pleasure, other factors

• Optional anchors

– Study current patterns (what feeds joy, what feeds low energy/sadness)

– What does client notice

– What would client be willing to do more of?

– What would client be willing to do less of?

121212

ACTIVITY MONITOR: LIST ACTIVITY AND GIVE MOOD RATING (0-10)

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Early morning(5-9)Late morning(9-12)Early afternoon(12-3)Mid-afternoon(3-6)

Evening(6-9)

Night(9- 12 am)

Overnight(12 - 5)

131313

S2: p 49

GOALS OF ACTIVITY MONITORING AND

SCHEDULING

• Activity Scheduling- help client to develop a schedule

– Emphasis on attempting the task, not on successful completion

• Schedule something

• Rate expected pleasure/accomplishment for the activity

• Rate the actual pleasure/accomplishment after right after completing it

– Goal is to help re-establish a routine

– Help to organize it in small steps with easiest first and progressing to more difficult

141414

STEP 3: HIERARCHY OF ACTIVITIES

• Develop hierarchy of routine, pleasurable and necessary activities

• Rate in terms of

– Most difficult

– Medium difficult

– Easy

Physiological

Safety & Security

Love/Belonging

Esteem

Self-Actualization

151515

STEP 4: PLANNING ACTIVITIES

PROVIDE A LIST OF PLEASANT AND PRODUCTIVE

ACTIVITIES

Time Planned Activity Actual Activity How it felt

7-8 AM ` Pleasant 0-10 ____

Productive 0-10 ____

8-9 AM Pleasant 0-10 ____

Productive 0-10 ____

(Format from Friedman-Yakoobian, Gottlieb, Hollow, Pinniniti, & Cather, 2007; used with permission)161616

REDUCE IMPACT OF NEGATIVE SYMPTOMS

Strategies to get active

• Focus on long-term goals

– Decrease pressure to achieve short-term results

– Explore client’s values to generate interest in goals

• Card sort and worksheets

• Consider very small and incremental steps

– Resist tendency to push client to do more

– Adds pressure to client further withdrawal

Deeper Dive: See Positive DataWorksheet

1717

S2: p 52

ADDRESS COMMON BARRIERS, CELEBRATE EFFORT, ACTIVELY GUIDE INTEGRATION OF POSITIVE WAYS

TO SEE SELF

• Explore Barriers: Negative Automatic thoughts- “can’t do anything”; “Used to be able to do more”; Gently explore.

• Celebrate: Effort and achievement- even smallest amount.

• Integrate: Ask questions like; “what does that say about you that you were able to do … when you thought you couldn’t?”

– Help person to notice and integrate positive information about self.

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SELF-PRACTICE OPPORTUNITY- SEE HANDOUTS

• Activity monitor- Self-rating for yesterday’s activities

– Pleasure and mastery/accomplishment/productive

• Planning activities

– From self-monitor

– From Group activity simple group activity

– Picking one

– Plan it

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COPING CARD

• Encourage client to write summary or take home points

– Helps put into own words experience of session

– Helps with memory

– May help to challenge underlying negative thinking

• “I can’t do anything”; note that in session they did things and “what does that say about him/her?”

20202020

NEGATIVE SYMPTOM SUMMARY

• Be mindful of expectations- lower pressure

• Look for small ways to increase activity in sessions

• Help to develop a simple activity schedule

• Help client to identify and then gently challenge negative cognitions/defeatist beliefs (often during in-session activity)

212121

Section 11: Being Open to Options and

Sticking with what works

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ENHANCING ADHERENCE AND RELAPSE PREVENTION

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CBT-P INFORMED ADHERENCE STRATEGIESDOES THE PERSON WANT HELP/TREATMENT?

If “No” I don’t want medicine ortreatment

If “Maybe”, but I don’t like the side

effects

If “Yes”, but there are obstacles like

forgetfulness

“Medicine is poison” – Thought

record

Back to common ground – values-

interests and things in common

Adherence tools discussion

Guide a review of issues – Decision

Balance

EDUCATION: CLARIFY MISINFORMATION IF

YOU ARE ABLE

• Typical benefits of medication

• Names and purposes of medications

• Common side effects

242424

BE A “COMMUNICATION COACH”

• Ask permission to participate with other treatment

providers (e.g. prescribers, therapists) with the patient so

that you can help the person talk about their thoughts

about medicine

• Help the client be an effective communicator

• If client refuses, then be gentle but honest – it’s

important that this communication gets passed on

– For those who are not court involved and not in-patient, reassure

them that no one will “make” them take medicine

252525

LEVEL 1 STRATEGY TO EXPLORE THOUGHTS ABOUT

MEDICATIONS

• Pros and Cons

262626

NO! WAIT! THAT’S PROS AND CONS, 360⁰

Make this about med adherence

Pros Cons

Do ………

Behavioral Experiment

I might discover that my fear is unfounded

I might have some fun

I might feel more independent

I’ll be afraid

I might screw up

I might look stupid to others

Don’t do…..

Behavioral Experiment

Feel less pressured

Feel relieved, until I feel this way again

I don’t have to work at this –others can do it for me

Don’t ever find out if I could really do it

Benefits are only short term

I stay dependent on others

27

IMPORTANT: Only use this technique when you can be truly neutral about the outcome; otherwise it could backfire!

2727

RECOVERY REVIEW Pat Deegan- Common Grounds

282828

Process Video

• Describe the difference between Pat’s description of recovery and her doctor’s description of recovery?

• How did Pat deal with this?

• How would you handle questions about medication adherence?

• What might you do if a client of yours did not want to take medicine?

29292929

COMMON VIEWS ON TAKING MEDICINE

• By a show of hands:

– How many of you like to take medications?

– How many would like to take medications daily?

– How many like to talk with others about your medications or medication schedule?

– Rate your comfort level in talking with doctors about your medication experiences

– (0----------------------------50---------------------------------100)

not at all moderately very

303030

WHAT WE KNOW ABOUT ADHERENCE

• Difficult for most

• Reasons for non-adherence have to do with beliefs about

– Illness

– Medicine

– Ease/difficulty of taking

– Benefits and costs of taking medicine

313131

WHEN CLIENT IS TAKING MEDICATIONS: SUPPORT HEALTHY MEDICATION HABITS

• Reminders: Pill boxes, notes to self in strategic locations, reminder calls from friends, pair medication taking with other routine activities (breakfast, coffee, etc.)

• Reinforcement: Develop simple rewards for successful medication adherence (treat self to something- coffee, movie, etc.)

323232

FOR MAINTAINING ADHERENCE

Adherence Solution Card - memory aid and reinforcement guide

Box 1: List medication, dose, when to take

Box 2: Things to talk with doctor about (see power statements)

Box 3: Practical strategies for taking medicine

Box 4: Personal factors that promote adherence

Box 5: Ways to reward self for adherence

S2: p 54

WRAP-UP

• Practice groups

• Exploring the client’s views about taking medicine

– Explore pros/cons of taking meds

– Help client communicate concerns with prescriber

• Providing accurate information, education, and support health habits with practical strategies

343434

ADHERENCE EXAMPLES

• Client says taking medicine; family says he is not

– What to do

• Client expresses ambivalence about meds

– What to do

• Client stopped taking meds 3 weeks ago, now showing symptoms; life is disrupted

353535

Special TopicsSection 12

Suicide

Homicide

Crises

Lets Review Special Topics together –

Handout Package

3636

THERAPIST SELF CARE

3737

SELF-CARE FOR THE MENTAL HEALTH PROVIDER

• Recognize the challenges of working with psychosis

• Prioritize Self in schedule: Holistic Self-Care

– Mind -Emotions -Work

– Body -Spirit -Relationships

• Modify the thoughts that hurt us (see Norcross (2000). Psychotherapist self-care… Professional Psychology Research and Practice, 31, 710-713).

– Wishful thinking (risk is when we become passive and avoidant)- think “active”

– Self-blame (hurts us and uses valuable energy)- know our limits, be gentle with ourselves, think “process and effort,” not outcome!

383838

SELF-CARE THOUGHT RECORDSituations that bother

me at work

List my thoughts

about it:

List Emotions:

Check thinking

• Check for wishful

thinking or self-

blame.

• Can I control the

outcome?

• Is this all on me or

can others help?

Action plan /

Outcome

Emphasis:

1. Problem solving

2. Improving

emotions

3. Support/Team-

who do I go to?

4. Review my holistic

self-care plan. Any

gaps?

393939

STAYING WELL AND SELF-CARE FOR THE MENTAL

HEALTH PROVIDER

• Savor successes (little and big)

• Relax- there are many ways to find peace of mind and body

• Grow through your experiences and share- Gratitude and TEAM

• Consider using a starter kit for self-care:

– http://socialwork.buffalo.edu/resources/self-care-starter-kit.html

404040

Conclusion

A FEW FINAL QUESTIONS AND COMMENTS

SECTION 14

4141

REVIEW WITH YOUR GROUP

(REVIEW SELF-REFLECTION CARDS)

• Most helpful

• New insights

• Areas you want to practice?

• What do you want to learn more about?

42424242

SUMMARY OF APPROACH

• Build collaborative relationship

– Befriending/Finding common ground

– Acceptance

– Normalization

• Understanding and Strategies for…

– Hallucinations

– Delusions

– Negative symptoms

– Adherence

REVIEW

• CBT-p shows benefits for treating psychotic symptoms

– Involves general mind-set and specific techniques/methods

– Application of techniques depend on degree or training, job role, and context

• In order to improve:

– Important to practice, discuss with team and receive feedback

444444

Consultation

WHAT’S NEXT?

Support

454545

DAY 3 PREVIEW

What is Fidelity

Cultural Humility

Outcome Measures andHow to Use Them

Practicums

A note on family and friends

464646

CLOSE

• Review- Feedback and Questions

• Take home work- Steps before next team meeting

• Complete evaluations and surveys please!

Thank you,

Harry J. Sivec, Ph.D.

CBT-p Consultant & Trainer

BeST Center at NEOMED

hsivec@neomed.edu

Valerie Kreider, Ph.D., LPCC-S, LICDC-CS

BeST Center at NEOMED

CBT-p Consultant & Trainer

vkreider@neomed.edu474747

References

• Friedman-Yakoobian, Gottlieb, Hollow, Pinniniti, & Cather, (2007). CBT Client Manual.

• Grant, P. & Beck, A. (2009). Defeatist beliefs as a mediator of cognitive impairment, negative symptoms, and functioning in schizophrenia. Schizophrenia Bulletin, 35(4), 798-806.

• Norcross, J. C. (2000). Psychotherapist self-care: Practitioner-tested, research-informed strategies. Professional Psychology: Research and Practice, 31(6), 710–713. https://doi.org/10.1037/0735-7028.31.6.710

• Tully, L.M. (PowerPoint presentation that also cited Ellis et al. 2013; Morrison et al. 2004) UCDavis.https://behavioralhealth.ucdavis.edu/sites/g/files/dgvnsk2356/files/events/slides-symposium/slides-psychosis-12-13-17/tully-121317.pdf