Compassion-focused therapy for critical hallucinations and shame in psychosis

CFT is based on the concept of self-nurture having been ‘switched off’ and the principle that we can reactivate our ability to be caring and self-nurturing. People often lose the ability to self-nurture and express compassion for others as a result of adverse life events in childhood and adolescence. People experiencing psychosis can be self-critical, self-blaming and have a negative outlook on the external world, along with strong feelings of shame which can maintain both positive and negative symptoms. Often, they do not feel deserving of therapy and this can lead to drop out from sessions (Box 1).

CFT helps to make sense of these self-blaming and critical thinking styles and to replace them with a more sympathetic and warm inner ‘voice’. This can be achieved through practising self-nurturing and compassionate behaviours and thinking using rational responding (Reference GilbertGilbert 2009). CFT comprises many components, one of which is the process of creating an image/fantasy of the ideal nurturer and working with this image repeatedly until self-nurture becomes second nature. Other compassion-based approaches include writing a compassionate letter to yourself which is written in a kind, supportive and caring manner, loving-kindness meditation and compassion-based homework exercises (recording of compassionate actions in a diary), all designed to develop the ability to nurture the self and others (Reference Wright, Turkington and KellyWright 2014: pp. 189–191). Evidence suggests that CFT can reduce distress for patients in acute in-patient settings (Reference Heriot-Maitland, Vidal and BallHeriot-Maitland 2014) and can reduce distress from critical auditory hallucinations (Reference Mayhew and GilbertMayhew 2008). While CFT would appear to be a viable complement to the cognitive model, there are no randomised trials of CFT in the treatment of psychosis to date.

Eye movement desensitisation and reprocessing for comorbid psychosis and PTSD

EMDR is based on a clear biological model and it leads to reprocessing of distorted, distressing trauma memories. Treatment consists of eight phases (Reference ShapiroShapiro 2001):

1. 1 gathering a comprehensive assessment of the patient's life history and developing a treatment plan

2. preparing the patient

3. assessing traumatic events

4. desensitisation and reprocessing of trauma

5. installation of positive cognitions

6. body scanning

7. closure

8. re-evaluation.

EMDR has been shown to be an effective treatment for post-traumatic stress disorder (PTSD). In adult psychosis there is a strong link between childhood vulnerability, trauma and hallucinations, with a dose–response relationship (Reference Read, van Os and MorrisonRead 2005). Since many people who have experienced psychosis have a history of trauma, EMDR potentially has a place in the treatment of psychosis (Box 2). It is important that we treat the trauma, as it may be maintaining the patient's psychotic symptoms. Promising evidence suggests that mental imagery (which is a component of EMDR) can lead to reduction of psychotic symptoms (Reference MorrisonMorrison 2004). An increasing number of studies support the efficacy of EMDR in psychosis (Reference van den Berg and van der Gaagvan den Berg 2012, Reference van den Berg, de Bont and van der Vleugel2015; Reference de Bont, van den Berg and van der Vleugelde Bont 2013a,Reference de Bont, van Minnen and de Jonghb). EMDR would therefore appear to be a safe and acceptable treatment for people with comorbid psychosis and PTSD, but randomised trials are needed.

Acceptance and commitment therapy to improve functioning in chronic schizophrenia

ACT is a ‘third-wave’ therapy (following on from behavioural therapy and then cognitive therapy). It is based on acceptance, cognitive flexibility, cognitive defusion rather than cognitive fusion, mindfulness and empowerment through the development of new skills. ACT promotes the practice of committed action to move the individual towards identified values (Reference Hayes, Luoma and BondHayes 2006). It is common for people with chronic psychosis to become involved in repetitive negative behaviours such as shouting back at their voices in an attempt to suppress them; this behaviour tends to make the voices worse. Similarly, in the setting of a persecutory delusional system, social isolation can become an entrenched behaviour. Such behavioural approaches markedly diminish quality of life and social functioning, never mind achieving recovery targets such as valued goals (being a good parent, a good friend, etc.). If patients are able to learn how to accept the presence of their voices/delusions and to focus their attention instead on positive goals linked to values, this may reduce the distress of psychosis and provide more options for improved coping and reality testing. ACT encourages people to accept their symptoms of psychosis rather than avoid and suppress them; evidence suggests that ACT can reduce the risk of further hospital admissions and lower individuals’ conviction in their delusions (Reference Bach and HayesBach 2002). Increasing commitment to change may also increase engagement in positive action. Reference White, Gumley and McTaggartWhite et al (2011) found that people with psychosis who had received ACT had lower levels of depression and negative symptoms. Box 3 gives an example of how ACT can be used in managing voices.

Open dialogue to maintain social contact in early psychosis

Open dialogue is an approach piloted in Finland, and it is based on family/group therapy and a social constructivist approach. It emphasises the collaborative nature of much learning and stresses that early psychosis requires consistency and a group response. The approach works by engaging the patient, their family and their social network in open dialogue about the experience of psychosis. Ideally, this treatment is implemented within 24 h of initial contact with mental health services (Reference Seikkula, Alkare and AaltonenSeikkula 2001). The main principles of this approach are outlined in Box 4.

Promising results have come from studies investigating open dialogue for psychosis. In a preliminary cohort study, at the 2-year point 64% of patients receiving open dialogue had never taken antipsychotic medication and 83% were working, studying or seeking employment (Reference Seikkula, Alakare and AaltonenSeikkula 2003). At the 5-year point, social outcomes in terms of being in employment or in full-time education remained greatly increased for individuals who had received open dialogue (Reference Seikkula, Aaltonen and AlkareSeikkula 2006). Again, randomised trials are awaited.

Positive psychology techniques for negative symptoms of schizophrenia

Classic psychosocial approaches for negative symptoms of schizophrenia are based mostly on behavioural activation, with mastery and pleasure recording. Positive psychology techniques, including the scheduling of ‘flow activities’, fit in well (Reference Meyer, Parks and SchuelllerMeyer 2014). Typically, patients with negative symptoms experience reduced motivation and anhedonia, seeming to be stuck in a rut, with little volition to attempt or little capacity to enjoy new activities. Discussion with a relative can unearth old hobbies and interests that can be added to activity schedules. One patient who used to be a bird watcher became more motivated on considering the birds he could hear outside the window. He showed some increase in pleasure as he started to catalogue the different species. This gradually led to discussions about migration patterns.

Similarly, if there is affective blunting and alogia, a longitudinal formulation (time line) can search for peak experiences and attempt to recreate experiences of joy, success and exhilaration using imagery exercises. Most people with schizophrenia need help to rediscover such positive experiences and affects and then to practise re-experiencing them. Again, this can lead to breakthroughs in functioning. One woman who was able to recall a time of being extremely at peace when visiting a historic site decided that she wished to visit some nearby sites to see if she could re-experience that positive affective state.

Transdiagnostic therapy based on the method of levels

This approach to therapy is based on an engineering model of how the brain functions – perceptual control theory (PCT) (Reference PowersPowers 1973). MoL therapy was designed by Tim Reference CareyCarey (2006) as a clinical application of perceptual control theory. We all face goal conflicts all the time, such as ‘I should tell the truth’ versus ‘I shouldn't hurt anyone's feelings’, and usually the mind spontaneously resolves such conflicts. The basic principle of Carey's model is that mental distress can arise from emotionally ‘hot’ goal conflicts, and individuals may need help to identify these and resolve them. Carey postulates that the therapist needs to keep going ‘up a level’ to find any ‘hot’ goal conflict. This is achieved by asking the patient questions in relation to what it would mean to them if they did not achieve a stated goal. Conflicts can be witnessed in breaches in social contact, i.e. disruptions in the flow of speech or eye contact such as looking away or laughing at key points in the discussion. At these points the therapist asks which thought went through the mind just then.

A good example of a hot goal conflict might be a woman who was sexually assaulted by her father in childhood who now also has feelings of needing to care for him in his old age. This conflict might theoretically manifest as increased arousal, with hallucinations in various modalities, thought disorder and/or paranoia (Reference Carey, Mansell and TaiCarey 2014). So while a life-threatening event might lead to PTSD, a conflicted event could trigger psychosis.

The key techniques of MoL include questioning both sides of the conflict, accessing imagery that expresses the conflict and not relying on homework or agendas (Reference TaiTai 2009). All of the therapy work is done in session and the patient has full control over the number of sessions needed. This approach has never been used in its pure form for psychosis, but the questioning techniques have been used as a means of overcoming roadblocks in therapy. MoL techniques are therefore best used in cases of treatment-resistant psychosis when medication and other therapies are not leading to the expected progress.

Metacognitive therapy

This form of cognitive therapy was first described by Adrian Reference WellsWells (2009). The basic model is the self-referencing executive function (S-REF) model, which postulates that when symptoms persist, the patient has become locked into a cognitive attentional state (CAS). In the CAS a patient with a paranoid delusion might hold contrary beliefs about paranoia, such as ‘being paranoid will keep me safe’ and ‘paranoia means that I will be violent someday’. These contrary beliefs maintain an attentional focus on the paranoid belief, driving high levels of arousal and the activation of mental safety behaviours such as worry, rumination and thought suppression/control. Metacognitive therapy for psychosis became viable through recognition that worry and rumination directly exacerbate psychotic symptoms such as persecutory paranoia and distressing hallucinations (Reference Morrison, Pyle and ChapmanMorrison 2014).

Key techniques include considering the pros and cons of worry and rumination in terms of their effectiveness in ensuring safety, worry/rumination periods (15 minute spells during which intense worrying/rumination are encouraged) and worry/rumination postponement, along with exercises to change attentional focus. Detached mindfulness as a technique is taught within metacognitive therapy to help reduce distress related to voices and paranoid thoughts. These strategies all lend themselves to a briefer form of cognitive therapy focused on process rather than content. This approach was piloted for psychotic disorders by Reference Morrison, Pyle and ChapmanMorrison et al (2014). Worry/rumination periods and postponement have proven to be of value for patients with persecutory delusions (Reference Freeman, Dunn and StartupFreeman 2015). These early results are promising, in that patients with prominent rumination and worry who are able to understand the model seem capable of deriving benefit, but it must be said that some patients just don't get it. This is particularly true of those with prominent cognitive deficits and primary negative symptoms (Box 5).

Cognitive adaptation training for those with severe cognitive deficits

People with chronic schizophrenia tend to complain most about their cognitive difficulties. Cognitive remediation attempts to remedy these cognitive, social and thinking deficits and errors using a series of exercises. It has been shown that attention and short-term memory can thus be improved, but the effect size is small and non-durable, and there is only modest generalisation to function (Reference Wykes, Huddy and CellardWykes 2011). Social skills training is a form of social remediation and has a stronger evidence base. It is a prominent psychosocial treatment, particularly in North America. At the level of cognitive deficits such as theory of mind and the ‘jumping to conclusions’ error, cognitive training programmes have recently been piloted and have been shown to be of benefit (Reference Moritz, Andreou and SchneiderMoritz 2014).

Cognitive adaptation training is a clinical intervention that takes cognitive remediation out of the classroom and into the patient's home environment. Cognitive adaptation training theory postulates that individuals with poor executive function require high levels of environmental structure and more obviously placed environmental cues. Electronic cueing devices, arrows, lists, pillboxes that play tunes, signs and other environmental aids are all individually organised according to each patient's comprehensive cognitive assessment. A trained therapist visits weekly to monitor progress and adapt the intervention as needed. This approach has been shown to improve functioning and treatment adherence and reduce hallucinatory intensity in chronic schizophrenia (Reference Velligan, Tai and RobertsVelligan 2015). Reference Allott, Killackey and SunAllott et al (2016) also demonstrated the feasibility and acceptability of cognitive adaptation training in first-episode psychosis. Box 6 illustrates a typical patient who might be responsive to cognitive adaptation training.

Mindfulness training

Mindfulness is a core concept of Buddhist religious practice and takes many forms. There is mindful walking, mindful breathing, mindful eating (e.g. the raisin exercise) and mindfulness meditation. The key principle is to develop the faculty of being aware of your own consciousness and to neutrally observe the flow of thoughts and other mental experiences without feeling the need to do something about them or becoming distressed by them. Thoughts are viewed as being transient experiences and the patient as a non-judgemental observer. The capacity to be mindful therefore fits in well as a treatment modality for those with distressing paranoid thoughts/beliefs and hallucinatory experiences. Mindfulness would be classified as a metacognitive coping style and it can completely change a person's attitude to their experience of psychosis. Mindfulness may also be cost-effective as it is usually practised in a group setting as a complement to other treatment modalities. There are, however, caveats. For example, some mindfulness exercises (such as the body scan) can be distressing for those with an undisclosed history of trauma.

Mindfulness training is a very useful new direction in the treatment of psychosis, as long as the intensity is titrated against degree of disability and rate of progress. The various exercises, once taught, are usually given as homework exercises carried out in a ‘pulsed format’, i.e. in brief bursts (Reference Wright, Turkington and KellyWright 2014): it is not recommended that people with psychosis spend prolonged periods in meditative states. An exercise might be to take a mindful breath whenever they walk through a door or whenever the adverts come on the television. The most successful applications to date have been in the area of voice hearing and persecutory paranoia (Reference ChadwickChadwick 2014). Although mindfulness is a promising approach for schizophrenia spectrum disorder, the current evidence base is very limited. The ideal patient for a mindfulness group might be someone who is distressed and preoccupied by the experience of voice hearing.