Psychosis: Counseling the Hallucinating or Delusional Patient
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Transcript of Psychosis: Counseling the Hallucinating or Delusional Patient
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Psychosis:Counseling the Hallucinating or
Delusional Patient
Presented by Ron Broughton, M.Ed., L.P.C.Chief Clinical OfficerBrookhaven Hospital
Tulsa, Oklahoma
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ObjectivesObjectives
1.1. Overview of medications & efficacyOverview of medications & efficacy2.2. Historical examination of the role of Historical examination of the role of
psychotherapy with psychotic patientspsychotherapy with psychotic patients3.3. Review recent research of CT/CBT Review recent research of CT/CBT 4.4. Learn specific therapy strategies for Learn specific therapy strategies for
psychosispsychosis5.5. Overview the of ABC modelOverview the of ABC model
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Definitions• Delusion: a false belief based on an incorrect inference
about external reality that is firmly sustained despite what almost everyone else believes, and despite what constitutes incontrovertible and obvious proof or evidence to the contrary.
• Hallucination: a sensory perception that has the compelling sense of reality of a true perception but that occurs without external stimulation of the relevant sensory organ
• Is it inside or outside? Interestingly, the DSM-IV “makes no distinction as to whether the source of the voices is perceived as being inside or outside of the head.”
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Charlie Brown’s View
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Research on Psychotherapy and Psychosis
Three Recent Eras
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Psychotherapy 1960-1975
Medicationvs.
Therapy
Medication SuperiorFocus
OnProblem Solving
Experienced Therapists
Better Outcomes*
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Psychotherapy 1980-1995
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The Early Theme
1. Psychodynamic approaches not effective2. Strong therapeutic rapport3. Personal therapy more effective4. Experienced clinician + individualized
approach = better outcome
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An Evolution Begins
Creativity is a drug I cannot live without.
--Cecil B. De Mille
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Evolvement in the Late 90’s
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The Late 90’s Results
Compared to supportive & psychoeducational treatment
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Don’t Forget Your Favorite College Course
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CBT Research & Hallucinations
Reduces & decreases severity
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CBT Research & Hallucinations
Increases quality of life
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CBT Research & Hallucinations
CBTMedication
Coping
SkillsFamily
Therapy
Integrative Approach
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CBT Research & Hallucinations
Overall, CBT
IMPACTS
Hallucinations
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CBT Research & Delusions
Studies Have Mixed Results
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CBT Research & Delusions
• Some no effect until follow-up• Early decrease, not @ follow-up• Others:
• 1/3 with decrease in conviction, preoccupation & anxiety
• 1/3 No change• 1/3 In between
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Client Satisfaction
Was treatment positive/helpful?
•CBT = 70% “Yes, definitely”•ST = 37%•TAU = 30%
Reason unclear, perhaps the therapeutic relationship?
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Strategies
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Strategies
Establish a strong therapeutic rapport
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Strategies
1. Stress reduction2. Relaxation techniques to stabilize3. Systematic desensitization to stabilize4. 5,4,3,2,1 to stabilize5. Normalize the experience6. Do Not use “delusion, hallucination,
psychosis”7. Know the belief well
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Strategies
8. Verbal challenge—the evidence9. Voice logs10. Client write out delusional content11. Evidence logs12. Change topic if client agitated13. Relapse prevention plan
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Therapist Role—Some Tips
1. Avoid waiting for the “meds to kick in”2. Be reliable, predictable & dependable3. Simple, honest accurate communication4. Have a healthy curiosity—reflection &
restatement of content5. Walk in the delusion, don’t collude with it6. Restrict use of silence, or watch the eyes7. If agitated, go to a neutral topic
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The ABC Model for PsychosisThe Philosophy
Noumenon An object as it is in itself, independent of the mind.
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The Philosophy
Our reality is interpreted through our senses & beliefs,
The “B” of the ABC Model
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Delusions on a Continuum
Less Normal MoreAll of us fall on the continuum.
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5 Principles of the ABC Model
1. All clinical problems are C’s.2. Problems arise from B’s not A’s.3. There are predictable connections
between B’s and C’s.4. Core B’s arise from early experiences.5. Weakening beliefs weakens associated
distress & disturbance.
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Eight Basic Steps
1. Client defines a problem2. Assess A or C3. Assess the one that remains4. Connect A to C & determine that is the
clients primary worry5. Assess beliefs, inferences & evaluations
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Eight Basic Steps
6. Formulation: Show the B-C connection Offer a developmental formulation
7. Set client’s goals & consider his options– Avoid or escape– Do nothing– They can change them in some way– Reduce by changing core beliefs
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Eight Basic Steps
8. Challenge beliefs Disputing and testing inferences Disputing and testing evaluations
Note: this is sequence of conceptual steps, not of technical ones. Lengthy & dynamic process.
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Case Study #1
1. Delusional set Excessive religiosity Minimal ADL’s Reading the Bible and prayer only
2. Interventions Assessed A’s Assessed C’s Assessed B’s (inferences, evaluation & interpretation) Challenged B’s Family therapy
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Case Study #2
1. Indeterminate delusional set Highly intelligent Mathematics wiz “Word salad”
2. Interventions Assessed A’s Assessed C’s Unable to assess B’s Focused on health & safety
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Review
1. Brief overview of medications & efficacy2. Historical examination of the role of
psychotherapy with psychotic patients3. Review recent research of CT/CBT for
psychosis4. Learn specific therapy strategies for
psychosis5. Overview the ABC model
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Some Conclusions
1. Therapeutic work lengthy2. Rapport is essential3. Requires patience and empathy4. DO NOT try to convince client 5. Use Socratic dialogue—client draws on his own
experience & doubt6. ABC model and schema therapy
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Questions?
Thank You!