Psychosis:Counseling the Hallucinating or

Delusional Patient

Presented by Ron Broughton, M.Ed., L.P.C.Chief Clinical OfficerBrookhaven Hospital

Tulsa, Oklahoma

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

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.”

Charlie Brown’s View

Research on Psychotherapy and Psychosis

Three Recent Eras

Psychotherapy 1960-1975

Medicationvs.

Therapy

Medication SuperiorFocus

OnProblem Solving

Experienced Therapists

Better Outcomes*

Psychotherapy 1980-1995

The Early Theme

1. Psychodynamic approaches not effective2. Strong therapeutic rapport3. Personal therapy more effective4. Experienced clinician + individualized

approach = better outcome

An Evolution Begins

Creativity is a drug I cannot live without.

--Cecil B. De Mille

Evolvement in the Late 90’s

The Late 90’s Results

Compared to supportive & psychoeducational treatment

Don’t Forget Your Favorite College Course

CBT Research & Hallucinations

Reduces & decreases severity

CBT Research & Hallucinations

Increases quality of life

CBT Research & Hallucinations

CBTMedication

Coping

SkillsFamily

Therapy

Integrative Approach

CBT Research & Hallucinations

Overall, CBT

IMPACTS

Hallucinations

CBT Research & Delusions

Studies Have Mixed Results

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

Client Satisfaction

Was treatment positive/helpful?

•CBT = 70% “Yes, definitely”•ST = 37%•TAU = 30%

Reason unclear, perhaps the therapeutic relationship?

Strategies

Strategies

Establish a strong therapeutic rapport

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

Strategies

8. Verbal challenge—the evidence9. Voice logs10. Client write out delusional content11. Evidence logs12. Change topic if client agitated13. Relapse prevention plan

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

The ABC Model for PsychosisThe Philosophy

Noumenon An object as it is in itself, independent of the mind.

The Philosophy

Our reality is interpreted through our senses & beliefs,

The “B” of the ABC Model

Delusions on a Continuum

Less Normal MoreAll of us fall on the continuum.

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.

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

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

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.

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

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

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

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

Questions?

Thank You!