Intro to CBT-p Model: Using CBT-p informed strategies for symptoms:

STRUCTURE OF SESSIONS AND HALLUCINATIONS

Harry Sivec, Ph.D. BeST Center, Northeast Ohio Medical University To get CME/CEU Attendance for today: Go to www.eeds.com or use eedsiPhone/Android App

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The Activity Code for this Session​​

Complete EEDS NOW SECTION 1

Section 1 Review Foundations

Putting together case info Case Review and Discussion Structure of session

Hallucinations CNN Video- HW- give reactions Voice Hearing Activity Coping with Distressing Voices #1 Practice Coping with Distressing Voices #2 Practice BRIDGE FROM FOUNDATIONS (DAY 1) TO ROLE- SPECIFIC APPLICATION (DAY 2) • What stayed with you most from the foundational/ Day 1? • What would like clarified today?

• Day 2 goals: apply skills to reduce distress/reach goals • Let’s talk about your most common challenges…

CBT-p and recovery Apply strategies & to symptoms of strategies

This Photo by Unknown Author is licensed under CC BY-SA ESSENTIAL RECOVERY ENHANCEMENT PRACTICES • View /psychosis w/ a Recovery Mindset. – Hope and Optimism • Develop a trusting relationship – Build from strengths, interests, values • Approach all concerns with an open and curious mind – Listen and reflect-back what you hear • Teach and learn together – Provide information that normalizes – Teach about Stress vulnerability and resilience – Show how cognitive model helps one understand – Solve challenges together- shared decision making! SOME SUGGESTIONS FOR LEARNING AND PRACTICING STRATEGIES

Your Adaptive mode Welcome uncertainty Build from your Develop tolerance for not strengths knowing the answer, and to be ok with exploring options. Remember that you have a team supporting you! TEACHING AND LEARNING TOGETHER

• The relational aim is to What do I wonder what you think? would happen if be a co-equal we tried this…

• The task is to co- discover meaning and

• To identify and check out new ways to think and act in situations HW REVIEW: THE CASE OF JOE- HANDOUT

• What are possible engagement strategies?

• Using the cognitive model : – What behaviors are problematic? – What history could inform us about this behavior? – What may he be telling himself (self-talk) that leads to his behavior? – What would you be curious to learn more about? REMEMBER: ORGANIZE CASE INFO TO GUIDE INTERVENTIONS Behavioral History Beliefs and Thoughts target What behavior is Recent and Thoughts lead to Behavior problematic or Remote getting in the What is this person saying way? to himself about the What events in this problematic behavior, person’s life may situation, or distress? That need to be have helped to addressed shape this behavior or What defeatist beliefs struggle might they hold about themselves?

(adapted from Creed, T., and the Beck Initiative, 2014) GROUP CASE REVIEW OF CURRENT CLIENT

Understanding is the first step to helping USE THE FORM TO GUIDE THE INTERVENTION- HANDOUT Client’s recovery goals: what does client really want to work on?

What are the client’s strengths and supports?

Symptoms/behaviors that interfere with meeting goals and how do they interfere?

Current stressors:

What would you like help with? Question for today’s consult

What have you tried so far (attempted skills/action)? USE THE FORM TO GUIDE THE INTERVENTION What do we know about the client history, beliefs, behavior)?

History: any life experience that helps us to understand the symptoms and behavior?

Beliefs: What does client tell self that might affect the symptoms or behavior?

Behavior: What does client do that helps or gets in the way of goals/values

Consultation/team suggestions:

Action plan: Skill/strategy to practice: POSSIBLE TREATMENT TARGETS?

• As a case manager, what kinds of interventions might you think about doing? What is scope of practice for you?

• How might you work with the therapist and prescriber in this situation?

• As we review strategies today, think about how the strategies may apply to this case** STRUCTURE FOR SESSIONS

Advantages and Disadvantages START STRUCTURE

• Preview START model for next session – Preview START POWTOON – Identify areas for practice using START model Structure Task Observations Make it safe and comfortable to talk. Be Conversation starter kind and friendly and refrain from giving Area of interest identified or brought up Socialize advice unless asked Keep in mind the client’s recovery goals- Topic (specific)= pick 1-2 targets Explored topic with gentleness, curiosity Target/Topic You may talk about many things, but try to pick one thing to begin, to work on, Reflected content so client felt heard and to conclude. Explore client’s concern- LISTEN Expand client’s understanding: What was most distressing or interesting to client for Work on the task of the day or steps to action? Action with compassion address current concern; • Did client have choices? OR Steps to help client reach goal • Were decisions shared? Encourage client input Remember to • Was action important to client? collaborate and to share decision • Was relevant education or normalization shared? making • Connected interest to value to goal

Ask client for feedback: What did client take away from meeting? What was helpful/not helpful today? Review What sticks with you the most today? Anything we missed?

What would you like to work on What is one valued action to do before the next meeting? between now and the next time we Take-home work meet? 16 START WITH DIALOG+ PROMPTS- HANDOUT Structure Prompt Observations How was your week? What was one thing you were most satisfied with / proud of this week? Casual conversation around this topic Socialize What would you like for us to work together on today? OR if already have a target, can we check on X from last time? *What is most distressing? Reflect back response; can you tell me more? Target *So, based on what you’ve said, is it ok if we work on ______today? (distress item or goal/task to work on) What is working? OR how have you gotten this far?

Looking to the future, what is the best-case scenario here? Action What would you like to be different? What is the smallest improvement you could see? -What are you willing to try? -What could I do? -Anyone else could help? What was helpful/not helpful today? What sticks with you the most today? Review

What is our plan of action before our next meeting? Your task; My task; other person’s task Preibe, et al., 2015 Take-home work START APPLIED Case example • S- Relationship connection first • T- Find something to work on – Understand concern / question • A- Explore options – Find out what has been working (MOBILIZE RESOURCES) – What gets in the way – Work together to find some small action step

• R- review learning • T- take home-work: commit to action plan

Breakout rooms COPING STRATEGIES- HALLUCINATIONS Start with strengths Offer options

19 VOICE HEARING

The following activity is optional. Please review the disclaimer. If you elect not to participate, please respond accordingly in the poll we will post after disclaimer has been read.

Disclaimer The following exercise was developed to reflect voice hearing . As such, you will hear a variety of voices and some voices will be confusing, critical, and potentially very distressing. This activity is not recommended for individuals who have a history of voice hearing. In order to simulate authentic voice hearing experiences, the audio may contain profanity and explicit language that some may find to be offensive. It is by no means our intention and the BeST Center of NEOMED is not responsible or liable for any distress caused. We advise that you exercise your right to withdraw from the simulation exercise, at any point, should you wish to. Voice Hearing Disclaimer Poll (Zoom Poll)

Please click accept in the poll to indicate that you have read and understand the disclaimer and wish to participate in the exercise, or you may elect to not participate (turn off sound and watch until exercise has completed). We will return on this slide:

Training participants are encouraged to also discuss their experience of the simulation exercise (positive or negative) with another staff member who has completed this exercise. In group training we have found that talking about this experience with others to be very helpful. You may also speak with your team leader or the BeST Center consultant trainer assigned to your team if you have any questions or concerns. Activity begins on next slide. You have 30 seconds to answer Question 1 Which one of these math equations is correct?

A. 24 * 5 = 110

B. 468 / 12 = 37

C. 857 – 29 = 828

D. 100 + 40 + 1000 + 30 + 1000 + 20 = 3090 You have 30 seconds to answer Question 2 / Answer in chat box Select the 5 most recent past presidents of the United States.

A. B. Clinton E. R. Reagan B. G. Ford F. B. Obama C. G.H. Bush G. D. Trump D. G. W. Bush H. J. Biden You have 30 seconds to answer Question 3 Which of these 5 words were previously mentioned?

A. Cigar, Snow, Damage, Cat, Book

B. Rain, Hazard, Cigar, Cat, Book

C. Cigar, Rain, Cat, Damage, Book

D. Book, Dog, Rain, Cigar, Snow HOW DOES VOICE HEARING AFFECT AN INTERVIEW? FORMING A RELATIONSHIP?

• What did you experience? • What did you observe? • What strategies did you use as voice-hearer? BARRIERS TO ENGAGEMENT: MENTAL HEALTH PROVIDER FACTOR

• When observing voice hearing, what were your thoughts/beliefs about – The client and – Yourself? • What emotions did you experience? • What did you do? (that helped/hindered engagement) CNN – EXERCISE IN EMPATHY HTTPS://WWW.YOUTUBE.COM/WATCH?V=YL9UJVTGPZY 1. WHAT WE UNDERSTAND ABOUT VOICES • Hearing voices is common – Human brains are vulnerable to psychotic like symptoms such as hearing voices or experiencing a presence

– So under certain circumstances, almost anyone could experience hallucinations

❑Sleep disruption ❑Illnesses ❑Certain stressful situations ❑Sleep deprivation ❑Medical conditions ❑Trouble separating internal ❑Medications events from external events ❑Illicit drugs ❑Feeling judged or criticized by ❑Neurohormonal issues others

28 1. WHAT WE UNDERSTAND ABOUT VOICES

• Voice content is closely linked with thinking – One idea is that brain events that would otherwise be experienced as thoughts, are (miss) classified by the brain as involving sound coming from a source external to self. • Source Monitoring error and Hallucinations

– Trauma and physiology are thought to play a role in this altered experience of thought/sound pathways in the brain.

From van der Gaag et al (2013)

29 THE ANATOMY OF VOICE HEARING (VAN DER GAAG, ET AL., 2013) HALLUCINATIONS OFTEN REFLECT LIFE EXPERIENCE • Role of trauma – Childhood physical and sexual abuse related to voice hearing • Content often reflects person’s history of interpersonal trauma

• Voices may reflect – internal thought (critical)/core beliefs – Intrusive memory of past trauma and/or effort to deal with trauma

31 2. BELIEFS ABOUT VOICES • Beliefs about voices often lead to distress – Voices are powerful o I have no control over voices – Voices know everything – Voices intend to harm / help me

• Common reactions- based on beliefs – Shock, fear, isolation 3. HOW TO ASK QUESTIONS ABOUT VOICES- HANDOUT • Make is safe: Hand signal or other method to start/stop talking about voices

• If client is willing- explore – What the voices say (content) • How the content affects the hearer? • What is the meaning of the voices?

– Where the voices come from (inside/outside of head). • If outside, exactly where do the sounds seem to come from Socialize Target Action Review/Feedback Take-Home work

33 EXPLORE/EMPATHIZE

• Do others hear voices? If not, how do they explain that? • Who is speaking? Reason? Voice known to client? • How does the client respond when he/she hears the voices? – How much control does the client have?

34 HOW TO ASK WHEN A PERSON APPEARS TO BE HEARING VOICES • Guidelines/Micro-skills: Exploratory mode – Ask permission – Describe what you observe – See if they are willing to describe their experience – In this context, what would be helpful? • Proceed without addressing: I’m here when you want to talk • Ask to explore: If bothers you, would be ok if we discuss? • Short term strategy for relief: what have you tried, would you be willing to try other things? (possible use of handout- upcoming slide) • Practice 35 LEVEL ONE PRACTICE:

Get comfortable asking about voices

Break out room: One person role play hearing voices Other person role play asking questions

36 PROCESS THE PRACTICE

• Observations: what worked / where did I get stuck?

• Practice feedback 4. INFORMATION ABOUT VOICE HEARING: THINGS YOU CAN SAY TO YOUR CLIENT

Main points: • It is not uncommon- – Many have heard voices at least once – You work with several people who hear voices (if this is true)

• It is nobody’s fault- combination of stress, biology and genes

• Stress Affects voices- can make it worse

38 MORE THINGS YOU CAN SAY ABOUT VOICES TO NORMALIZE AND EDUCATE More on stress:

• Have you ever heard about situations that lead to voice hearing? (check their response and give examples below).

– Grief, loss, trauma, illness, extreme stress, sleep loss, drugs are common reasons

– Seems like some situations make the brain sensitive to hearing voices- what do you think of that? NORMALIZING STATEMENTS FOR PSYCHOSIS

• Unusual and distressing experiences happen for many individuals. • Sometimes stress can lead to unusual experiences. • Sometimes a person’s brain can misread situations. • Some people develop psychotic experiences and are diagnosed with schizophrenia. It is not the person’s fault. Like other conditions/illnesses, it is usually a combination of genetics, a person’s biology, and stress. • The good news is that there are treatments and interventions that can help people to live satisfying, meaningful lives. LEVEL TWO PRACTICE

Normalizing information

Breakout room: One person hears voices Other person practices providing normalizing information

41 PROCESS THE PRACTICE

• Observations: what worked / where did I get stuck?

• Practice feedback COPING WITH DISTRESS CAUSED BY VOICES TOOL KIT

• Tools for addressing distressing voice hearing experiences

Socialize Target Action Review/Feedback Take-Home work DISTRESS CAUSED BY • Activation – Volume turned up – Too many things turned on

• Dysregulation – Volume or on/off switch not working – Lights flickering/internet losing connection

This Photo by Unknown Author is licensed under CC BY-NC-ND

Coping plan: Lower activation Increase sense of control

45 STRATEGIES TO REDUCE DISTRESS: TURN ATTENTION TO CALMING ACTIVITY

• Distraction Strategies • Re-Focusing Strategies – Humming – Prayer, meditation, – Take a relaxing “time out” mindfulness – Listening to music – Guided relaxation – Exercise – Art work

46 STRATEGIES TO REDUCE DISTRESS: ENHANCE SENSE OF CONTROL OVER THE VOICE

• Set limits: Dismiss the voices or set limits

• Attention shifting: Rate voice→ then Look, Point, Name objects → Re-rate; notice impact on voice (Beck institute)

• Sub-vocalization- read quietly to self; name objects – Use earplug with sub-vocalization – Haddock, Tarrier, et al. (1998)

• Positive, affirming statements – Counter negative voice content

47 COPING WITH DISTRESSING VOICES WORKSHEET- HANDOUT

• What do they say? • How intense/distressing? • When does it interfere? • What has helped? • What hasn’t helped? • Willing to consider other coping options? – If no, can provide normalization

See “Coping with distressing voices” worksheet

48 TWO PART DISTRESS-REDUCTION PLAN: LOWER ACTIVATION + INCREASE CONTROL

1. Listen and normalize • What already doing that helps? 2. Breathing / Relaxing- Finger tip breathing 3. Re-direct Attention- Look, Point, Name method 4. Positive, valued action 5. Positive, affirming statement (to counter voice content)

• TIP: Less is More, pick one and notice impact

49 FIVE POINTS FOR WORKING WITH DISTRESS

Attention Positive action

Breath/relax Positive statement

Listen normalize

This Photo by Unknown Author is licensed under CC BY-SA 50 LEVEL ONE PRACTICE: PART 2

Coping with Distressing Voices

Break out room One person plays voices Other person offers a coping idea

51 VOICE INTERFERENCE WITH DOING TASKS AND ERRANDS • Guidelines: – Explore impact and current strategies – Is the task/errand important to larger goal/value? – Strategies for emotions- e.g., Breathing – Strategies for thoughts- e.g., Other ways to think about this? – Wonder about one small step toward your goal? Socialize • Check how today’s session went and Target Action • What to work on in between sessions Review/Feedback Take-Home work

52 SUMMARY

• Make it safe to talk about voices • Try to understand the client’s point of view – Meaning of voices, how managing at present, what they want to do • If person wants to do something about the voices: ❖Strengthening coping strategies

53 RESOURCES

• See distraction and focusing handouts • Coping with voices: Self-help strategies for people who hear voices that are distressing (Pat Deegan) • Think You’re Crazy? Think Again: A Resource Book for Cognitive Therapy for Psychosis (Morrison et al., 2008) • Homework: explore one of these websites: – www.compassionforvoices.com – inter-voice: http://www.intervoiceonline.org/ – https://strong365.org/psychosis-101/how-to-cope-with- voices/ RECAP ON VOICES AND HOMEWORK CHOICE

• What stood out to you about working with individuals who hear voices? • What skill would you like to practice? • HW: investigate one of the three websites REFERENCES

• Amador, X. (2000). I Am Not Sick I don’t Need Help: How to Help Someone with Mental Illness Accept Treatment. New York: Vida Press • Case review framework: Adapted from Creed, T. and Beck Institute, 2014.

• Deegan, P. Coping with voices: Self-help strategies for people who hear voices that are distressing. National Empowerment Center.

• Look, Point, Name method: From Recovery Oriented Cognitive Therapy. See Grant, P.M., Reisweber, J., Luther, L, Brinen, A., and Beck, A. (2014). Successfully breaking a 20-year cycle of hospitalizations with recovery oriented cognitive therapy for schizophrenia. Psychological Services, 11, 125-133.

• van der Gaag, M., Nieman, D., and van den Berg, D. (2013). CBT for Those at Risk of a First Episode Psychosis. Evidence-based for people with an ‘At Risk Mental State’. Routledge: London. (Anatomy of voice hearing) PREP WORK FOR PARANOIA

• David Kingdon- demo example of speaking with someone with paranoia. Go to…

• David Kingdon 1 Engaging person with paranoia https://vimeo.com/19414316 • David Kingdon 2 Tracing origins of paranoia https://vimeo.com/19411683 • David Kingdon 3 Examining evidence https://vimeo.com/19412849 Intro to CBT-p Model: Using CBT-p informed strategies for psychotic symptoms DELUSIONS

Harry Sivec, Ph.D. BeST Center, Northeast Ohio Medical University To get CME/CEU Attendance for today: Go to www.eeds.com or use eedsiPhone/Android App

Enter in your information including type of license in the Degree field and your license number.

The Activity Code for this Session​​

Complete EEDS NOW SECTION 2

Section 2 Objectives Delusions Understanding Empathy Strategies Negative Symptoms Understanding Empathy Strategies Summary Action plans for practice REVIEW OF HOMEWORK AND QUESTIONS

• What did you practice and learn? – Lessons learned – Questions

• How many explored a website? – Which one and what did you find? – Questions BEN’S STORY OBSERVE AND REFLECT

• What would it be like to have the experiences that Ben describes?

• Based on your training so far, what symptoms (distressing experiences) did you observe?

• What was “delusional” in his presentation? DELUSIONS EMPATHY PUT YOURSELF IN THE CLIENT’S POSITION

Empathy is a choice, and it’s a vulnerable choice. In order to connect with you, I have to connect with something in myself that knows that feeling. Brené Brown EMPATHY EXERCISE 1

• Use chat box to provide your response to each instruction WHAT IS BEHIND YOU?

This Photo by Unknown Author is licensed under CC BY-SA-NC UNDERSTANDING

Write your own self-reflection notes ? PERCEPTION, THINKING AND CONSENSUS REALITY

• We see some things in common and understand certain social conventions/ Consensus (see Francis, 2019) • We also have our own Private or personalized way to see things This Photo by Unknown Author is licensed under and realize there are other ways to see it CC BY-NC • Beliefs rigidly held that defy logic/evidence and fall outside of consensus reality, with distress and interference= delusions

Delusion Private Reality Consensus Private Reality Self Reality Other THE DEVELOPMENT OF A DELUSIONAL BELIEF

Selective Notice confirming info attention, biased Interpret in negative way; recall Recall negative Anxiety distress, sleep- disruption The appraisal of the Appraisal- experience combined “demons” with anxiety and distress form the distressing belief

Unusual experience Could originate from stress; physiology, substances See Garety et al., 2001 EMPATHY EXERCISE 2: TALKING WITH SOMEONE ABOUT A DELUSION* • Two-person empathy exercise- “That’s not true”

• Empathy- for the described experience – Whether “true” in or not, it is experienced as factual by the person. – Try to see and feel the situation from their point of view.

• How would I like someone else to respond to me if this were true for me?

Amador, X. (2000). I Am Not Sick I don’t Need Help: How to Help Someone with Mental Illness Accept Treatment. NY: Vida Press Nelson, H. (2005). Cognitive Behavioral Therapy with Delusions and Hallucinations: A Practice Manual. 2nd Edition. Nelson Thornes: UK. GUIDELINES FOR TALKING ABOUT DELUSIONS- HANDOUT

• Suspend disbelief and explore in a neutral, curious way – Do not directly challenge or agree with a delusion – Try to learn more about what they believe – Listen: Reflect what you hear without reacting or changing information.

Socialize Target Action Review/Feedback Take-Home work HOW TO ASK QUESTIONS: DEMO

• Ask questions to understand- “eyewitness testimony type questions” • Help me understand… when did it start, how did you come to know this? Walk me thru a recent example step by step. Keep emotion low. • How have you handled it? – What has been helpful? What has not been helpful? • IF client says: “Do you believe what I say is true?” delay with respect – No reason to doubt you, but no way of knowing for certain. Can I gather more information before I answer that question? SMALL REALITY CHECKS • Small checks to see if thinking is flexible or if there is doubt – Indirectly floating ideas- have you ever wondered about…? • Any chance something else may be happening? • Or maybe some information that may be missing? • Tip: disclose a time that you misread a situation because you did not have all of the information; note how common it is to do this for all of us. • Can use alternative explanations exercise as an introduction – Was there ever a time you were not 100% sure about this? – What does your family, friends, say about this? What do you make of that? – Wonder how we could check this out in small way? “HELLO MARGE, THIS IS GLADYS UP THE STREET. FINE, THANKS… SAY, MARGE, COULD YOU GO TO YOUR WINDOW AND DESCRIBE

WHAT’S IN MY FRONT YARD?” LARSON PLANTING A HEALTHY MIND GARDEN • There is something about planting a seed thought • Sometimes, just saying, “Hmmmm, I wonder about………”, how they monitor when the power goes out”… or “interesting that you have survived so long with no physical harm…” then… – Don’t say anything more! Let the statement be – The idea/”seed” may grow (you have introduced an alternative bit of information to consider, but you don’t force them to respond) – Change in thinking may occur many months later TOOL KIT

• Identify “problem” or target- not belief directly, but what the belief gets in the way of

• Sleep Socialize • Going places Target Action • Feeling stressed Review/Feedback Take-Home work • Identify a tool kit item that will help with this.

• When done ask what was helpful and what they can do in between meetings LITTLE STEPS- VIDEO EXAMPLE

• Tiny experiments or little checks – People are after me! • Look up to see if everyone is staring or just some or no one – Ever a time in the past that this didn’t happen? • Get details • Wonder about different reasons/explanations for events – Alternative beliefs exercise combined with mini self- disclosures • Test out new ideas and link to goals – What if we tried going to the store and asking a question?

78 AN EXAMPLE OF WORKING WITH PARANOIA

79 REVIEW CASE MANAGER WORK WITH PARANOIA

80 PROCESS VIDEO: POLL

• What did you notice about what the case manager did?

• What did the client find most helpful?

• Is this an approach that you would feel comfortable using with one of your clients?

81 DISCUSSION GROUPS- BREAK OUT ROOMS PICK ONE OPTION

1. Practice asking a person about their experience

2. Share a situation with a delusion interfered with an activity and as a group brainstorm how to address it

82 SPOKESPERSON FEEDBACK

• Report out one lessons learned YOU DON’T HAVE TO ADDRESS THE BELIEF DIRECTLY

• Sometimes, a delusion is so strong and rigidly held, that it does not change no matter what intervention we use • We may notice the client is tired of talking about it with you • Can always refocus to pursuing valued goals – Lots of folks in the United States hold very odd beliefs and still • Go to work • Get married or at least date • Make friends • Have hobbies • Work on a plan to do some of the things they value LIFE GOES ON

• Let’s get them going about daily life with the belief on board if that is necessary

• Brain storming comes in handy – So, demons threaten you, you’ve learned that nothing has happened so far, what needs to happen so that God can leave you alone or honor your boundaries while you’re at work – You’d like to begin driving again, lets think about how you will manage with the voices on board WHEN PARANOIA IS DIRECTED TOWARD A TEAM MEMBER • State clearly you concern for the person and desire to help them reach their goals • Express empathy for person’s lack of trust • Open self to feedback and evidence supporting the belief • Evaluate the information supporting distrust and look for missing information or evidence to the contrary (e.g., pointing out times you or other team members have provided assistance or support) • Normalize- based on life experiences, beliefs are very understandable, makes sense that you want to protect self. Can also lead to biases and over attention to some information. • Practice of emotion regulation skills (e.g., breathing, grounding) prior to starting meetings as a way to lower activation

Adapted from Pinninti et al., 2007 Cognitive Behavioral Therapy for Individuals Diagnosed with Schizophrenia Spectrum Disorders: A Treatment Manual for Case Managers, p.32. Used with permission SUMMARY, REFLECT, REVIEW AND TAKE HOME

• Key points-

• Action plan: something you can practice.

• Remember the alternative thinking exercise as a way to practice expanding thinking if client is up to it. handout UP NEXT

• Negative Symptoms

• Depression and suicide risk • Anger and violence risk • Adherence and medication issues Intro to CBT-p Model: Using CBT-p informed strategies for symptoms: NEGATIVE SYMPTOMS; DEPRESSION; SUICIDE/VIOLENCE RISK

Harry Sivec, Ph.D. BeST Center, Northeast Ohio Medical University To get CME/CEU Attendance for today: Go to www.eeds.com or use eedsiPhone/Android App

Enter in your information including type of license in the Degree field and your license number.

The Activity Code for this Session​​ SECTION 3

Section 3 Negative symptom review Cover ways to work on a simple schedule Depression and suicide risk Identify depression and risk issues Anger and violence risk Identify risk issues for violence

Summary Review and Discussion NEGATIVE SYMPTOMS

This Photo by Unknown Author is licensed under CC BY-SA NEGATIVE SYMPTOMS

Diminishment/absence of characteristics of normal function – something taken away

Examples Loss of interest/pleasure in everyday activities Appearing to lack emotion (flat affect)

Reduced ability to plan or carry out activities

Neglect of personal hygiene

Social withdrawal (asociality) & limited speech (poverty of speech)

Loss of motivation ()

93 WHAT WE UNDERSTAND ABOUT NEGATIVE SYMPTOMS- HANDOUT • 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 VIDEO CHECK

About to watch a short didactic video on behavior activation

0= won’t like it at all, will be kind of boring

10= will love it, will be very enjoyable

https://www.youtube.com/watch?v=EtH9Yllzjcc 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 • Action- Avoidance INTERVENTION MINDSET

• Expectation adjustment (for clinician, client, and family) – Think about amount of loss experienced and how people “normally” respond when facing so much loss – Loss of control; sense of self – Loss of job – Loss of income – Loss of relationships

(Kingdon & Turkington, 2005) MINDSET FOR NEGATIVE SYMPTOMS INJURY, REDUCE PRESSURE, STRENGTHEN, REWARD

• Consider a back injury:

• Typical initial behaviors – Guarding and protecting • How to get at barriers? Maintenance formulation This Photo by Unknown Author is licensed under CC BY-SA

– Thoughts- “man this is going to hurt if I move” – “never going to get better” – Feeling- fear, apprehension – Behavior- stay in one position or lie down frequently- impact= no immediate pain, but boredom and slow recovery

• What is commonly recommended? 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 Socialize Target • Remind them that recovery happens! Action Review/Feedback Take-Home work 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 REMEMBER VALUE/GOAL SHEET

Modified form from Periviolitis START WITH A VERY SIMPLE SCHEDULE

• When are you at your best? List…. • When do you smile/What makes you smile? List… – How much pleasure do those activities bring? – Rate sense of accomplishment?

• Help client to add one or two new activities – Rate activity when doing it to help reinforce the experience when doing it. START WITH A SIMPLE PLAN/PERSONALIZE IT- HANDOUT

Day/Time Planned Activity Actual Activity How it Felt

Pleasant 0-10: ______

Productive 0-10: _____

Pleasant 0-10: ______

Productive 0-10: _____

Pleasant 0-10: ______

Productive 0-10: _____

Pleasant 0-10: ______

Productive 0-10: _____ TOOL KIT

• Encourage person to participate in activities with you • Encourage person to record how much he/she enjoys something when doing it (keep track) • Help to build a schedule – Goal is not to complete anything; Goal is to attempt many things.

Socialize Target Action Review/Feedback Take-Home work SIMPLE IN-SESSION / ON THE PHONE WAYS TO GET ACTIVE AND CONNECT

• Cards • Checkers • Walk and take in the sights/sounds

• Games Socialize • Breathing training Target • Other: GROUP activity- demonstration Action Review/Feedback • Rate activity in the moment Take-Home work

• Ask what was most helpful today and what they might do between meetings EXPLORE BARRIERS, CELEBRATE EFFORT, INTEGRATE SUCCESS

• Explore: 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. PRACTICE SCENARIOS DISCUSSION GROUPS- BREAKOUT ROOM

• In apartment, doesn’t want to leave

• In car, not speaking- what to do?

• Sleeping most of the day

• Defeatist attitude- client says, “nothing is going to work”; “can’t do anything”

• Summary of ideas and things to try

107 CBT-P FOR NEGATIVE SYMPTOMS • “Negative symptoms and dysfunctional beliefs freeze a person into a shell of avoidance and withdrawal to shield from disappointment”

CBT-p

• “CBTp strategies help to break out of shell by mobilizing personal and social resources to facilitate meaningful re-engagement in their lives” Adapted from Perivoliotis and Cather, 2009, p. 828 HW: PRACTICE OPPORTUNITIES • For someone who appears flat and lacking emotion… • Watch Powtoon example of activity schedule • Read manual- sections 2-3 REFERENCES

• Amador, X. (2000). I Am Not Sick I don’t Need Help: How to Help Someone with Mental Illness Accept Treatment. NY: Vida Press.

• Francis, R. (2019). On Conquering Schizophrenia: From the desk of a therapist and survivor.

• Garety, P., Kuipers, E., Fowler, D., Freeman, D. & Bebbington, P. (2001). A cognitive model of the positive symptoms of psychosis. Psychological Medicine, 31, 189-195.

• Granholm, E.L., McQuaid, J.R., Holden, J.L. (2016). Cognitive-Behavioral Social Skills Training for Schizophrenia: A Practical Treatment Guide. New York: Guilford Press.

• Grant, P.M. & Beck, A.T. (2009). Defeatist beliefs as a mediator of cognitive impairment, negative symptoms, and functioning in schizophrenia. Schizophrenia Bulletin, 35, 798- 806. • Kingdon, D. & Turkington, D. (2005). Cognitive Therapy of Schizophrenia. New York: Guilford. • Nelson, H. (2005). Cognitive Behavioral Therapy with Delusions and Hallucinations: A Practice Manual. 2nd Edition. Nelson Thornes: UK • Pinninti et al., 2007 Cognitive Behavioral Therapy for Individuals Diagnosed with Schizophrenia Spectrum Disorders: A Treatment Manual for Case Managers, p.32. OVERVIEW OF RISK ISSUES

Depression and Negative Symptoms Suicide risk Violence risk DEPRESSION AND SCHIZOPHRENIA • COMMON – Prevalence of Depression in Schizophrenia: 40% – When looked at longitudinally, up to 80% in early phase.

• IMPORTANT – Significant in suicide in schizophrenia (more so than command hallucinations) – Linked with transition from UHR to psychosis – Mediating effects: • Harsh parenting in childhood (small effect on developing psychosis) mediated by depression/anxiety • Similar for (even smaller effect)- locus of control more important here • From Upthegrove, et al., 2017 THREE PATHWAYS TO DEPRESSION IN SCHIZOPHRENIA

1. Depression is a core dimension of psychosis 2. Depression is a shame-based response to the diagnosis of schizophrenia and internalized stigma- lots of research here 3. Depression is the evidence of historical childhood abuse-

Adapted from Upthegrove et al., 2017 WHAT ARE THE DIFFERENCES BETWEEN NEGATIVE SYMPTOMS AND DEPRESSION?

Negative Symptoms Depression Core Symptoms Flat Affect Depressed Mood Poverty of Speech** Asociality Guilt / Worthlessness Anhedonia Weight Loss or Gain Avolition Other Suggested Symptoms Other Suggested Symptoms Insomnia or Sleep Excess Psychomotor Retardation Suicidal Ideation Fatigue Psychomotor Retardation/Agitation Withdrawal Fatigue/loss of energy Apathy Decreased Concentration Distractibility Adapted from Pogue-Geile, M. (1989). Negative Symptoms and Depression in Schizophrenia, Book Chapter from Depression in Schizophrenics, pp. 53-65 Ed. Richard Williams, J. Thomas Dalby HOW TO DETERMINE RELATIVE BALANCE OF DEPRESSION TO NEGATIVE SYMPTOMS

• Calgary Depression scale: focus on these features – Depression- reports of depression and sadness – Hopelessness- view of future; thoughts about life as hopeless – Guilt- sense of blame (check also for worthlessness) – Suicidal ideation

• Remember the cognitive triad of depression!

This Photo by Unknown Author is licensed under CC BY-SA NEGATIVE SYMPTOM OR DEPRESSION?

• From a CBT-p standpoint: more important to ask, to what extent do…

– Environmental factors influence the different symptoms • What can we help to change in the context of a person’s life?

– Psychological processes (unhealthy thinking habits; safety behaviors) may mediate this influence. • What thoughts help to maintain avoidance or depression?

• Adapted from Morrison et al., 2004 INSIGHT PARADOX

• Higher insight is associated with better treatment adherence • Higher insight also associated with depression, low self- esteem, low quality of life • The “insight paradox” (more insight, more engagement, but more depression) appears to be moderated by stigma (Staring et al., 2009) – High insight, low stigma (hope) have the best outcomes – Increasing hope in persons with schizophrenia may directly and positively increase quality of life and “usefulness” of insight (Hasson-Ohayon, et al., 2009)

Hasson-Ohayon, I., Kravetz, S.,, Meir, T., Rozencwaig, S. (2009). Insight into severe mental illness, hope and quality of life of persons with schizophrenia and schizoaffective disorders. Psychiatry Research, 167, 231-238. Staring et al. (2009). Stigma moderates the associations of insight with depressed mood, low self-esteem, and low quality of life in patients with schizophrenia spectrum disorders. Schiz Research, 115, 363-369. CASE MANAGEMENT WITH DEPRESSION AND PSYCHOSIS

• The approach for negative symptoms and depression is similar – Increase activities that are associated with meaning or pleasure/joy.

– Affirm strengths and positive steps. • What does that say about you that you are able to do… x, y, z? encourage them to affirm meaning (e.g., “I can do things”; “people do like me”; etc.)

This Photo by Unknown Author is licensed under CC BY-NC-ND SUICIDE RISK

handout RISK FACTORS FOR SUICIDE IN FIRST EPISODE (COENTRE, ET AL., 2017) • Depressive symptoms • History of sexual abuse • Comorbid polysubstance use • Lower baseline functioning • Recent negative events • Longer “duration of untreated psychosis” (DUP) • Higher positive and negative symptoms scores • Previous suicidal attempts* • High insight with higher premorbid functioning (for both males and females – varies from study to study)

Suicide attempts after FEP ranged from 2.9% to 18.2% Completed suicide rates ranged from 0.4% to 4.29% PSYCHOSIS AND SUICIDE RISK

• Negative view of the psychosis may account for the depression-hopelessness-suicide relationship • Common feelings in early psychosis – Loss – Entrapment – Humiliation/shame

• What can be improved in This Photo by Unknown Author is licensed under CC BY-SA person’s situation/environment?

See Jackson and Iqbal, (2000) WITH SUICIDE RISK • What is your agency policy, procedure or standard of practice? • Everything starts with a good relationship! Trust and safety – Ask about suicidal thoughts, ideas, plans, or any actions that may lead up to a suicide action – Check on any protective factors – Consider formal risk assessment, if this is possible on your team. – If suicidal ideas with plan, role of case manager is often to keep client safe to the extent possible, by things like preventing access to means of self-harm; transporting to an emergency setting etc. • If necessary for police to be involved, request a CIT trained officer WITH SUICIDE RISK , CONT’D

– If suicidal thoughts with no plan, get a sense of person’s positive coping skills and prior history of dealing with these types of thoughts. – Consult and communicate with team members and supervisors to develop a safety plan.

Adapted from Pinninti et al., 2007 Cognitive Behavioral Therapy for Individuals Diagnosed with Schizophrenia Spectrum Disorders: A Treatment Manual for Case Managers, pp 61-62. Used with permission ANGER, AGGRESSION AND VIOLENCE RISK

This Photo by Unknown Author is licensed under CC BY-SA-NC PSYCHOSIS AND VIOLENCE RISK (SEE SCOTT AND RESNICK (2013), CURRENT PSYCHIATRY, VOL 12, NO5; KEERS ET AL. (2014), AM. JOURNAL OF PSYCHIATRY, 171:3)

• Higher risk of violence with untreated psychosis • Areas of risk: – Persecutory delusions • Assess degree of perceived threat • Assess safety behaviors (i.e., likelihood of self- protective aggression) • Assess associated levels of anger, sadness, anxiety PSYCHOSIS AND VIOLENCE RISK, CONT’D

Command auditory hallucinations (risk higher when) • Voice is perceived as benevolent and powerful (person has no control) • Delusions are consistent with the commands • Voices lead to negative emotions (anger, sadness, anxiety) • Person has few coping strategies for voices WITH HOSTILITY AND RISK OF HARM • What is your agency policy, procedure or standard of practice? • Ensure safety (be aware of warning signs) and plan ahead (e.g., if visiting client in the community, be aware of recent notes in chart and or information from team meeting). • Acknowledge Anger- “I see that you are very angry right now” • Engage in conversation about the things bothering the person – Remain calm and neutral; reflect back content to ensure understanding – Check on the key risk areas, Command Hallucinations and paranoia – Help person to see their strengths in the situation • Validate legitimate Issues- e.g., “sorry I could not call you yesterday” WITH HOSTILITY AND RISK OF HARM, CONT’D- HANDOUT • Help client develop a coping response to concerns (e.g., what would help increase sense of safety right now? What are some ways that you have handled this well in the past? Would you be willing to consider other coping responses here?) • If significant concerns about risk to others due to delusions or Command Hallucinations… – Consult with team members, enlist help of family or friends for safety planning – If necessary for police to be involved, request a CIT-trained officer

Adapted from Pinninti et al., 2007 Cognitive Behavioral Therapy for Individuals Diagnosed with Schizophrenia Spectrum Disorders: A Treatment Manual for Case Managers, p54-56. Used with permission DISCUSSION OF RISK ISSUES AND CHALLENGES

• Break-out rooms:

• Identify situation involving depression or hostility and discuss potential approaches

• Report out the main take home points for working with Depression, Negative symptoms, and risk issues. REFERENCES • Coentre, R., (2017). Depressive symptoms and suicidal behavior after first-episode psychosis: A comprehensive systematic review. Psychiatry Research, 253, 240-248.

• Hasson-Ohayon, I., Kravetz, S.,, Meir, T., Rozencwaig, S. (2009). Insight into severe mental illness, hope and quality of life of persons with schizophrenia and schizoaffective disorders. Psychiatry Research, 167, 231- 238.

• Jackson, C. and Iqbal, Z. (2000). Psychological adjustment to early psychosis. In M. Birchwood, D. Fowler, and C. Jackson, Eds). Early Interventions in Psychosis. Wiley.

• Keers et al. (2014), Am. Journal of Psychiatry, 171:3

• Morrison, A. P., Renton, J. C., Dunn, H., Williams, S., & Bentall, R.P. (2004). Cognitive Therapy for Psychosis: A Formulation- Based Approach. New York: Routledge.

• Perivoliotis, D. & Cather, C. (2009). Cognitive Behavioral Therapy of Negative Symptoms. Journal of Clinical Psychology: In Session, 65(8), 815-830.

• Pinninti et al., 2007 Cognitive Behavioral Therapy for Individuals Diagnosed with Schizophrenia Spectrum Disorders: A Treatment Manual for Case Managers, pp 61-62. Used with permission

• REFERENCES

• Scott and Resnick (2013), Current Psychiatry, vol 12, No5;

• Staring et al. (2009). Stigma moderates the associations of insight with depressed mood, low self-esteem, and low quality of life in patients with schizophrenia spectrum disorders. Schiz Research, 115, 363-369.

• Upthegrove, R., Marwaha, S., & Birchwood, M. (2017). Depression and schizophrenia: Cause, consequence, or trans-diagnostic issue? Schizophrenia Bulletin. 43(2), 240-244. ADDITIONAL RESOURCE VIDEOS

• Amador Ted Talk- I’m not sick, I don’t need help

• https://www.youtube.com/watch?v=NXxytf6kfPM

• Insider view of voices- Ted Talk; Debra Lampshire https://www.youtube.com/watch?v=NjL2dqONIqQ