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Strengths-Focused Cognitive Behavioural Therapy for Psychosis and Schizophrenia

Our Conversations lecture 'Hope, Humanity and Empowerment: Strengths-focused Cognitive Behavioural Therapy for Psychosis (& Schizophrenia)' was presented by staff members of the Integrated Forensic, Recovery and Schizophrenia programs at The Royal.

Psychosis can be associated with a variety of mental health problems, including schizophrenia, severe depression, bipolar disorder, anxiety, and post-traumatic stress disorders. While traditional treatments for psychosis have emphasized medication-based strategies, research now suggests that individuals affected by psychosis can greatly benefit from talk therapies such as cognitive behavioural therapy for psychosis (CBTP).

Learn more:

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Strengths-Focused Cognitive Behavioural Therapy for Psychosis and Schizophrenia

  1. 1. Hope, Humanity and Empowerment: Strengths-focused Cognitive Behavioural Therapy for Psychosis (& Schizophrenia)
  2. 2. Agenda • Introductions and welcome (bilingual) • CBTP Origins and Strategies • Why a strengths, humanistic, meaning making and recovery oriented approach is so important (NAMI poster other slides) • Video • Goals and meaning • The whole person-complementing meds • Stigma • Peer Support: hope and empowerment • WRAP and recovery • Resources - family sessions • Q & A
  3. 3. Brought to you by…. The Integrated Forensics, Recovery and Schizophrenia Programs of The Royal With thanks to support from: •University of Ottawa Medical Research Fund •The Institute of Mental Health Research
  4. 4. Presenters • Tiffany Clough: Peer • Diane Hoffman-Lacombe: Psychologist, Forensics • Raphaela Fleisher: Social Worker, Forensics • Tom Fogl: Psychiatrist, Schizophrenia • Anik Gosselin: Psychologist, Forensics, Brockville MHC • Sandra Jacquens: Social Worker, Schizophrenia • Dylan Myllymaki: Social Worker, Schizophrenia • Carlo Verdicchio: Peer Support Worker, Recovery • Nicola Wright: Psychologist, Schizophrenia
  5. 5. Introduction to CBT for Psychosis: Origins & Strategies Presented by: Diane Hoffman-Lacombe, M.Ps., C.Psych Raphaela Fleisher, MSW, RSW
  6. 6. What is CBTp?What is psychosis? THOUGHTS EMOTIONS BEHAVIOURS CBT for Psychosis
  7. 7. What is Psychosis? • Psychotic experiences (eg. hallucinations, delusions can have difficulties with thoughts, behaviors and emotions) • Conceptualization of psychosis on a continuum • Delusions (unusual beliefs) that are not based on facts & hallucinations (unusual perceptions, such as voices) are part of human experience • Psychosis is a core feature of a number of different conditions (eg. schizophrenia, schizoaffective disorder, brief psychotic disorder, delusional disorder, etc.) • Can be a feature of bipolar, depression, post traumatic stress disorder, & other conditions) • Context is important: cultural norms, practices & beliefs
  8. 8. What is CBT for Psychosis (CBTP) • CBT = cognitive behavior therapy • Behavioral and emotional responses linked to cognitions – thoughts (appraisal of events; interpretation; perspective) • CBT is a form of psychotherapy developed by Dr. Aaron Beck (1960s) • Empirically validated for numerous conditions including psychosis/schizophrenia (see National Institute of Clinical Excellence Guidelines) • CBT for Psychosis (1990s-early 2000s) • Emphasize strong therapeutic alliance; psychoeducation & normalization; skills & strategies to address stress and reduce distress, symptoms such as delusions, hallucinations & lack of motivation are addressed as barriers to meaningful goals • Focus on STRENGTHS, VALUES, GOALS & RECOVERY
  9. 9. Objectives of CBTP • Enhance recovery / quality of life • Normalize emotions and experiences; give another way to look at experience • Normalize through psychoeducation • Finding meaning (making sense of unusual experiences; symptoms like hallucinations & delusions • Decrease distress through… • Coping tools and techniques • Skill development • Strategies to cope with symptoms that are barriers to MEANINGFUL GOALS, QUALITY OF LIFE & RECOVERY
  10. 10. CBTP Group: Topics for 17 Sessions • Intro to CBT (goals & pleasant activities) • CBT: what it can do for you (the CBT triangle and the ABC model) • Getting active & negative symptoms • Thoughts that get in the way of getting active • Thinking styles: noticing my thoughts & checking them out • Checking out troubling automatic thoughts • Voice hearing & other hallucinations • CBT Strategies for troubling thoughts & hallucinations • CBT Strategies: advantages & disadvantages and finding meaning • CBT Strategies: behavioral experiments • CBT Strategies for paranoid beliefs • CBT Strategies for unusual ideas & beliefs • Shifting Core Beliefs: Feeling Good About Yourself • Wellness Plan & CBT after the group • Booster Session / Practice group
  11. 11. Toolkit Sample: Coping Strategies • CBT triangle, ABC, 3C’s, 4C’s • Evidence for and Against, Decentering, Metathinking • Thinking styles • Coping cards-coping affirmations • Set meaningful goals • Develop a personal action plan • Take care of physical health –exercise, sleep, healthy diet, etc,.. • Take medications consistently • Cool hot thoughts -shift unhelpful thoughts • Notice & change “shoulds”, “musts” and “oughts” • Take the other person’s point of view • Focus on strengths, accomplishments, progress • Immerse in enjoyable activities • Develop positive emotions • Focus on the now instead of worries about the past or future • Practice mindfulness (1-2 minutes) & relaxation • Be kind to yourself-self compassion & self-care • Practice gratitude daily • Keep a positive log
  12. 12. The 3Cs and 4Cs - catch it, check it, change it (with compassion) Catch It (notice it) Check It Change It (shift) Compassion Everyone is looking at me when I’m in a mall. Is it true that everyone is looking at me? Not everyone is looking at me. Take a deep a breath and be kind to myself.
  13. 13. Forensic Considerations • Therapeutic Alliance / Relationship • Team Communication • Risk Management – risk assessment (HARM) – individual care plan
  14. 14. Why a strengths-focused, empowering, meaning making and recovery oriented approach is so important Nicola Wright, Ph.D., Psychologist, Schizophrenia Program, The Royal
  15. 15. Positive Psychology; Strengths- Focus • Focusing on what’s STRONG not what’s wrong • Optimal healthy human functioning • Strengths, qualities, skills, resources: promoting health • Humanistic: actualize potential-empower • Values, Goals, Dreams • Achieve meaningful lives • Coping strategies/skills • Meaning making –making sense of no(n)-sense
  16. 16. Positive Psychology; Strengths- Focus • Positive Emotions • 3:1 ratio • Negativity bias: threat & mistakes • Neurons that fire together wire together • Positive Memories • Imagery • Gratitude Exercises • Positive Log
  17. 17. Recovery-Oriented • Recovery= A meaningful life – How do we define success?
  18. 18. Empowerment-Resilience • Empowerment: – CBTP=shift thoughts & beliefs about self, others & the future – Enhance self-image – Voices-Social Rank Theory –power & control – Stigma – Motivates to move in valued directions to achieve meaningful goal • How: Skills, Knowledge, Understanding – Meta-thinking: Thinking about your thinking – Jumping to conclusions, worry, rumination, self-critical, avoidance, anxious or fearful thinking I used to think the brain was the most wonderful organ in my body. Then I realized who was telling me this. (Emo Philips)
  19. 19. Empowerment-Resilience • How: – Emotional regulation & resilience – Stress & distress –heightened-skills – You name it you tame it – What you resist persists-not avoiding • Eg., shifting relationship with voices
  20. 20. The ABC Model Activating Event Beliefs or thoughts Consequences (Feelings & Actions) Event or Situation Thoughts 1) Feelings 2) Behaviors Troubling thought example Voice says: “You are a loser” I can’t do this I will fail 1) Sad 2) Stay at home Balanced-helpful thought example Voice says: “You are a loser” Maybe the voice is wrong-I don`t have to believe the voice The voice is like a day time dream (or my mind playing tricks on itself)-I can do this 1) Confident 2) Go out
  21. 21. Empowerment-Resilience • Resilience: 3Cs – Commitment –to valued goals & feeling deeply involved – Control-have a sense can influence own life – Challenge- able to turn adversity into a challenge or opportunity for growth –illness as evolution • Resilience : – Face facts-Acceptance – Choose Life-Live for Future – Reach Out- to peers, supports – Get Moving-individual action plan – Give Back- gratitude & generosity
  22. 22. Empowerment-Resilience • Educate- empowers, normalize, develop understanding –not alone • Advocate- addresses stigma, creates resources, sense of purpose • Narrate-develop new empowering narrative re. self & life • Create- valued future • Metaphor or Image: • Mountains • Canoeing through rough waters to sunny beach
  24. 24. Values • Value consistent living • Move in valued directions • Motivation-always there • Courage • Strength • Inspirational • Resilience • Perseverance • Overcoming Hardship • Determination
  25. 25. Beauty & Hope • Compassion, connection, making a difference, going to the sacred painful places: co-traveller (mountain image)-our common human content • School • Peer Support Worker • Start own Business • Poet • Artist • Married • Kids
  26. 26. Video TED Talk: Eleanor Longden
  27. 27. Goals and Meaning By Dylan Myllymaki, MSW, RSW Social Worker The Royal
  28. 28. Fostering Meaningful Activities, Purpose, and Action • Goal planning in group and individual therapy • Integrate techniques from various therapies: – CBT (behavioural activation, SMART goal setting, problem solving, exposure, etc.) – Acceptance and Commitment therapy (identify core values, acceptance of uncomfortable thoughts/feelings, focus on present moment, decrease avoidance, committed action to valued goals) – Strengths based & recovery focused (identify strengths, develop hope, self-determination and personal responsibility, meaning making, create unique path to recovery)
  29. 29. Typical Goals & Core Values Typical goals of clients: 1.Romantic and family relationships 2.Work, employment, volunteering 3.Social relationships/peers Examples of core values: – Helping others, self-acceptance, generosity, stability, creativity, etc.
  30. 30. Focus on Meaning Creation • Main focus is on individual values, strengths, and growth; rather than symptoms and deficits. • Therapeutic relationship is key. Give up control, let the client take lead on goals. Be flexible, open-minded, and encouraging (mirror back what you would like to see with clients). • Experimental attitude – try out new experiences tied to values as methods to gather new information about self, others, and the reality of goals. • Positive emotions and new experiences can create new meaning. Emotions act as a primary motivator for action. • Symptoms are addressed as barriers to meaningful activities. • Values = compass for action (principles that person stands for, they are not goals). • No goals, no problem....focus on what is important and meaningful to that person. Explore and experiment. • Goals flow naturally out of strengths, values, and interests (past and present).
  31. 31. Barriers to Valued Goals • Ambivalence and resistance – use motivational interviewing techniques • Excessive goals – simplifying action plan, self-compassion if goal not attained, start with smallest first step (e.g. Thinking about goal) • Remoteness from values – goal is not in line with present values, goal introjected by others • Avoidance of discomfort – focus on accepting some discomfort (within window of tolerance), change is not easy • Lack of dreams, wishes, long term goals – use imagery to build a preferred future or connect with healthy parts of self from past (What would you like…… What would it look like if..?) • Lack of resources – build support system, understand needs • Psychotic symptoms – CBTp strategies
  32. 32. Complementing Medications: The Whole Person By Dr. Tomas Fogl, Psychiatrist, Schizophrenia Program
  33. 33. Video
  34. 34. The Stigma of Mental Illness Functions, consequences and … what next ? By Anik Gosselin, Ph.D., C.Psych. Clinical Psychologist and Forensic Neuropsychologist Forensic Treatment Unit, Brockville The Royal
  35. 35. Prejudice vs Stigma Prejudice: Antipathy based upon a faulty and inflexible generalization. Directed toward a group as a whole or toward an individual because he is a member of that group (Allport, 1954) focus on perpetrators •e.g., race and ethnic groups Stigma: Situation of the individual who is disqualified from full social acceptance. The stigmatized individual is reduced in our minds from a whole and usual person to a tainted, discounted one (Goffman, 1963) focus on targeted individuals •e.g., mental illness
  36. 36. Three Functions of Stigma and Prejudice (Phelan, Link & Dovidio, 2008) 1. Exploitation/domination (i.e., keeping people down) – e.g., racism 2. Enforcement of social norms (i.e., keeping people in) – e.g., obesity, smoking, homosexuality, criminal behaviour 3. Avoidance of disease (i.e., keeping people away) - e.g., mental illness, mental retardation
  37. 37. Effects of Stigma on the Targeted Individuals • Depression, demoralization, shame (Lucksted et al., 2011) • Social avoidance, distancing (Link et al., 2004) • Increase in symptom intensity (Livingston & Boyd, 2010) • Increase in hospitalization, decrease in engagement (Kvrgic et al., 2013) • Decrease in hope and in quality of life (Mittal et al., 2012) • Decrease in treatment adherence and in help-seeking (Vogel et al., 2013) • Poor self-esteem and self-efficacy
  38. 38. Progressive Model of Self-stigma (Corrigan & Rao, 2012) AWARENESS •“The public believes people with mental illness are weak” AGREEMENT •“That’s right. People with mental illness are weak.” APPLICATION •“I am mentally ill so I must be weak.” HARM •“Because I am weak, I am not worthy or able.” WHY TRY… to pursue a job: I am not worthy….to live on my own, I am not able.
  39. 39. The Why-try Effect(Corrigan et al., 2009) Stereotypes Blame Dangerousness Incompetence Fewer behaviours in pursuit of goals! Decreased participation in evidence- based practices Public Stigma Self-Stigma Awareness Agreement Application Social Mediators Self-esteem Self-efficacy
  40. 40. Stigma in Forensics – an additional challenge to recovery • The forensic label: a double stigma ‘I am violent and mentally ill; I scare people, I am not worthy of love; I have to hide’ • Housing difficulties
  41. 41. What Next? At the societal level: •Policy and law changes - make discrimination illegal (e.g., refusing a job or housing based on history of mental illness) •Decrease ignorance and preconceived ideas – Outreach to the public (e.g., a person with a mental illness comes and talks to different groups from the community) •Talk about it! For the stigmatized individuals: •Join peer support groups •Disclose •Promote personal empowerment
  42. 42. Disclosure Strategies (Corrigan & Rao, 2012) Social Avoidance Stay away from people so they don’t have a chance to stigmatize me Secrecy Go out into the world – work and go to church, but tell no one about my illness Selective Disclosure Tell people about my illness who seem like they will understand Indiscriminant Disclosure Hide it from no one Broadcast Be proud - Let people know
  43. 43. Peer work and CBT Presented by: Carlo Verdicchio, Peer Support Worker The Royal
  44. 44. My Role 1. Offering Support
  45. 45. 2. Holding Hope
  46. 46. 3. Exploring Recovery Remember: it looks different for everyone. Horizon Hope by Laura Harris
  47. 47. Peer Support in Recovery “Research findings document that individuals who use peer run services have decreased hospitalizations, suicide rates, and substance use, an increase in social contacts, ability to carry out activities of daily Living and a positive impact on participants’ recovery, including an increase in their empowerment, hopefulness, and informal learning of adaptive coping strategies.” J. Campbell in On Our Own Together: Peer Programs for People with Mental Illness:
  48. 48. Wellness From the December 2012 issue of the Canadian Foundation for Healthcare Improvement’s Mythbusters : “…a growing body of evidence is showing that recovery of meaningful life despite limitations imposed by illness is possible and likely. People with lived experience have known for some time that, with hope, empowerment and support from others, recovery is possible. Promoting a mental health system that views both personal and clinical recovery as the objective can reduce the healthcare costs, enhance quality of life, promote social inclusion, and help those living with mental illness lead full and productive lives.”
  49. 49. WRAP and Recovery By Tiffany Clough
  50. 50. Resources By Sandra Jacquens, MSW, RSW Social Worker, Schizophrenia Program The Royal
  51. 51. Resources for families and their loved ones The Royal A physician referral is needed for assessment in the Consultation Clinic or to request ongoing treatment. Website: Program Eligibility Criteria – Schizophrenia Program • Are aged between 18 to 65 • Have a working diagnosis or symptoms of Schizophrenia or a Schizoaffective Disorder • Have clinical needs that cannot be adequately addressed in the community or the general psychiatry setting, defined as: – Unstable symptoms or failure to respond well to medication – Psychosocial needs in at least three of the following five areas: – Basic tasks of independent living – Housing – Finances – Educational or occupational functioning – Ability to establish or maintain social support system • Have at least one of the clinical needs listed above and/or would benefit from clinical research activity in the Schizophrenia Program
  52. 52. Resources for families and their loved ones Champlain District Regional First Episode Psychosis Program – On Track (bilingual) Accepts individuals aged 16 to 35 years who are experiencing symptoms of psychosis who have: • less than six months of prior treatment, and • symptoms that are not explained by drug abuse or other mental health problems 613.737.8069 or 1.888.737.8069 Bank Street Professional Centre 1355 Bank Street Suite 208 Ottawa, Ontario K1H 8K7
  53. 53. What to do in a crisis • Contact your doctor • Go to the nearest hospital emergency room • Call 911 • Telehealth Ontario: 1-866-797-0000 (24 hours/day) • Ontario Mental Health Helpline/Ligne d’aide sur la santé mentale: 1-866-531-2600 • Youth Services Bureau (YSB) Crisis Line: 613-260-2360 (bilingual) • Mental Health Crisis Line in Ottawa: 613-722-6914 or outside Ottawa: 1-866-996-0991
  54. 54. How to acquire a psychiatric assessment When a person appears to be suffering from a mental disorder, but is unwilling to obtain help, a mental health assessment may be necessary. There are options for people who want to get an assessment for someone who is refusing to have one voluntarily. •Convince and support the person to get an assessment •By order of a physician •Justice of the Peace Order (Form 2) •Once a Form 2 is issued •If Form 2 is not issued
  55. 55. A Guide For Families and Individuals Navigating The Addictions And Mental Health System In Champlain ( Shortcut to photo.JPG.lnk
  56. 56. Handouts Available • Community Counselling Resources • Key Family Information and Support Resources in Ottawa • Family Information and Support Meetings (The Royal) • Family Education Series (The Royal)
  57. 57. References for Clients • Freeman, D., Freeman, J., & Garety, P. (2008). Overcoming paranoid and suspicious thoughts: A self-help guide using cognitive behavioral techniques. New York: Basic Books. • Hayward, M., Strauss, C., & Kingdon, D. (2012). Overcoming distressing voices: A self-help guide using cognitive behavioral techniques. London, UK: Constable & Robinson. • Morrison, A. P., Renton, J. C., French, P., & Bentall, R. P. (2008). Think you’re crazy? Think again: A resource book for cognitive therapy for psychosis. New York: Routledge / Taylor & Francis Group. • Turkington, D., Kingdon, D., Rathod, S., Wilcock, S. K. J., Brabban, A., Cromarty, P., et al. (2009). Back to life, back to normality. Cambridge, UK: Cambridge University Press. • Quintal, Marie-Luce et al. Je suis une personne pas une maladie ! La maladie mentale : l’espoir d’un mieux-être. Performance Édition. Québec. 2013 (not CBT specific but excellent référence générale sur le sujet)
  58. 58. References for Professionals • Beck, A. T., Rector, N.A., Stolar, N., & Grant, P. (2009). Schizophrenia: Cognitive theory, research, and therapy. New York: Guilford Press. • Beck, J. S. (2011) Cognitive behavior therapy : basics and beyond. New York: Guilford Press. • Byrne, S., Birchwood, M., Trower, P., & Meaden, A. (Eds.) (2006). A casebook of cognitive behaviour therapy for command hallucinations: A social rank theory approach. New York: Routledge / Taylor & Francis Group. • Gilbert, P. (2010). Compassion-focused therapy. New York: Routledge, Taylor & Francis Group. • Kingdon, D. G., & Turkington, D. (2005). Cognitive therapy of schizophrenia. New York: Guilford Press. • Meaden, A., Keen, N., Aston, R., Barton, K., & Bucci, S. (2013). Cognitive therapy for command hallucinations: An advanced practical companion. London, UK: Routledge / Taylor & Francis Group. • Morris, E. M., Johns, L. C., & Oliver, J. E. (Eds.). (2013). Acceptance and commitment therapy and mindfulness for psychosis. Chichester, UK: Wiley-Blackwell. • Nelson, H. (2005). Cognitive-behavioural therapy with delusions and hallucinations : a practice manual. Cheltenham, U.K.: Nelson Thornes. • Tarrier, N., Gooding, P., Pratt, D., Kelly, J., Awenat, Y., & Maxwell, J. (2013). Cognitive behavioural prevention of suicide in psychosis: A treatment manual. London, UK: Routledge / Taylor & Francis Group. • Willson, R. & Branch, R. (2006). Les thérapies comportementales et cognitives pour les nuls. Paris- France: Éditons First. • Wright, N.P., & al. (2014) Treating Psychosis. Oakland, CA: New Harbinger Publications, Inc. • Willson, R. & Branch, Rhena. Les Thérapies Comportementales et cognitives pour les nuls. Éditions générales First. France. 2006 (not CBT for psychosis specific)
  59. 59. Q & A Session

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Our Conversations lecture 'Hope, Humanity and Empowerment: Strengths-focused Cognitive Behavioural Therapy for Psychosis (& Schizophrenia)' was presented by staff members of the Integrated Forensic, Recovery and Schizophrenia programs at The Royal. Psychosis can be associated with a variety of mental health problems, including schizophrenia, severe depression, bipolar disorder, anxiety, and post-traumatic stress disorders. While traditional treatments for psychosis have emphasized medication-based strategies, research now suggests that individuals affected by psychosis can greatly benefit from talk therapies such as cognitive behavioural therapy for psychosis (CBTP). Learn more:


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