Brief cognitive behavioural therapy for hallucinations: Can it help people who
decide not to take antipsychotic medication? A case report.
(Short running title: CBT for psychosis without antipsychotics)
Paul Hutton1& Anthony P. Morrison
Psychosis Research Unit, Greater Manchester West Mental Health Foundation NHS
Trust, UK & University of Manchester, UK
Hannah Taylor
University of Manchester, Manchester, UK
Abstract
Background: Cognitive behavioural therapy (CBT) can be helpful for many people
who experience psychosis, however most research trials have been conducted with
people also taking antipsychotic medication. There is little evidence to know
whether CBT can help people who choose not to take this medication, despite this
being a very frequent event. Developing effective alternatives to antipsychotics
would offer service users real choice.
Aims: To report a case study illustrating how brief CBT may be of value to a young
person experiencing psychosis and not wishing to take antipsychotic medication.
Method: We describe the progress of brief CBT for a young man reporting auditory
and visual hallucinations in the form of a controlling and dominating invisible
Reprint requests to Dr. Paul Hutton, Psychosis Research Unit, Department of Psychology, Greater
Manchester West Mental Health NHS Foundation Trust, Bury New Road, Prestwich, UK, M25 3BL.
E-mail: [email protected]
1
companion. We describe the formulation process and discuss the impact of key
interventions such as normalising and detached mindfulness.
Results: Seven sessions of CBT resulted in complete disappearance of the invisible
companion. The reduction in frequency and duration followed reduction in
conviction in key appraisals concerning uncontrollability and unacceptability.
Conclusions: This case adds to the existing evidence base by suggesting that even
short term CBT might lead to valued outcomes for service users experiencing
psychosis but not wishing to take antipsychotic medication.
Keywords: Psychosis, cognitive behaviour therapy, hallucinations, imaginary
companions, antipsychotic medication
2
Introduction
Following a systematic review of treatment studies, the UK’s National Institute of
Clinical Excellence recommended over six years ago that all those who receive a
diagnosis of a schizophrenia-spectrum disorder in England and Wales be offered
cognitive behavioural therapy (CBT) in addition to standard care, which normally
includes antipsychotic medication and case management (NICE, 2002). CBT in
addition to standard care has been shown to demonstrate a moderate effect size in
reducing the frequency and intensity of experiences and beliefs classified as
psychotic (e.g., delusions and hallucinations) in comparison to standard care alone
(Wykes, Steel, Everitt & Tarrier, 2008).
No systematic studies of the efficacy of CBT for people who meet criteria for
established psychosis and do not wish to take antipsychotic medication have been
carried out, although several published case reports suggest it may be beneficial
(Beck, 1952; Morrison, 1994; Morrison, 2001; Christodoulides, Dudley, Brown,
Turkington et al., 2008). In addition, Morrison and colleagues found CBT and case
management helped prevent or delay transition to psychosis in an unmedicated
ultra high-risk population (Morrison, French, Parker, Roberts et al., 2007). This
finding, together with the hypothesis that the high-risk and established psychosis
population lie on a continuum of symptom severity and are not qualitatively
different (a hypothesis which has helped justify the research and development of
antipsychotic medication for treating people at ultra high-risk), supports the idea
that a similar approach might be beneficial for people meeting criteria for
established psychosis and not wishing to take medication.
Developing alternative interventions for this group of clients ought to be an urgent
concern given recent recommendations emphasising treatment choice in the NHS
(Darzi, 2008), the right of patients in England under the new NHS Constitution to
make informed choices about their treatment (Department of Health, 2009), the
problematic side-effects of both typical and atypical antipsychotics (Kane, Woerner
& Lieberman, 1985; Suvisaari, 2007), the significant proportion of people who have a
3
poor response to antipsychotic medication (up to 40%; Kane, Schooler, Marder,
Wirshing et al., 1996), the finding that many people choose to stop taking their
medication (up to 74% over 5 years; Lieberman, Stroup, McEvoy, Swartz et al., 2005)
and the observation that many retain treatment decision-making capacity (e.g.,
Owen, David, Richardson, Szmukler et al., 2008; Cairns, Maddock, Buchanan, David
et al., 2005). Importantly, not taking antipsychotic medication does not necessarily
imply people do not wish to receive some other form of effective help (Buchanan,
1992).
It is hoped that the case presented here will add to the evidence discussed above by
suggesting the possibility that even very short term CBT can be a helpful and
acceptable treatment for a young person meeting criteria for psychosis and not
wishing to take antipsychotic medication. The client read a draft of this anonymised
report and provided informed consent to publication.
Client History
Sandy, an 18-year old man who had heard and seen an invisible figure (‘John’) since
he was 10, was referred to the Psychosis Research Unit because of limited access to
psychological therapy in his local mental health service. He was highly distressed and
actively seeking help. He repeatedly heard John talking and singing, and could offer a
vivid and detailed description of his appearance. He described John as being as real
as other people, although he could offer little explanation for his existence or why
other people could not see him. He believed John to be completely uncontrollable.
He was frequently woken up at night by John singing and then instructing him to go
to the bathroom, which he complied with. He also reported complying with John’s
instructions to put the wrong answer in an exam and he found it difficult to
concentrate on conversations due to John’s constant singing. He did not wish to take
antipsychotic medication and had not done so previously. Although he had not
received CBT before he had received a successful intervention (family therapy,
counselling and brief inpatient care) for an eating disorder over a year previously. He
4
had not disclosed his invisible companion to professionals at the time as he did not
view it as a problem.
Assessment
Clinical assessment, including interview assessment using the Comprehensive
Assessment of At-Risk Mental States (CAARMS; Yung, Yuen, McGorry, Phillips et al.,
2005) and Psychotic Symptom Rating Scales for auditory hallucinations (PSYRATS-AH;
Haddock, McCarron, Tarrier & Faragher, 1999), suggested Sandy’s experiences were
of a nature, intensity, duration and frequency that met criteria for established
psychosis. Sandy met criteria for psychosis on the CAARMS because he had a severity
score of 5 on the perceptual abnormalities subscale together with a frequency score
of 5 (the threshold for psychosis on this subscale is a severity score of 5 or 6 and a
frequency score of 4, 5, or 6) and because these experiences had lasted longer than
a week (they had been continuous for the previous 8 years). He also had a severity
score of 5 on the unusual thought content subscale (frequency score of 2), a severity
score of 3 on non-bizarre ideas (frequency score of 3) and a severity score of 0 on
disorganised speech (frequency score of 0). Meeting criteria for psychosis on the
CAARMS requires a severity score of 6 and a frequency score of 4, 5 or 6 on the
unusual thoughts, non-bizarre ideas and / or the disorganised speech subscale. He
also completed a Beck Depression Inventory, 2nd Edition (BDI-II; Beck, Steer & Brown,
1996) which suggested moderate depression (see Table 1 for PSYRATS-AH and BDI-II
data).
Sandy identified his current problems as 1) being upset and controlled by John and
2) feeling irritable and angry. Further assessment suggested his compliance with
John’s night-time demands were currently affecting his sleep. This had led to several
incidents where he had been extremely distressed and sought reassurance from his
parents. Increased anger and irritability appeared to be involved in frequent
arguments between Sandy and his parents which had escalated to Sandy running
away from home at one point.
5
Sandy also completed an Interpretation of Voices Inventory (IVI; Morrison, Wells &
Nothard, 2002) which confirmed he felt he had no control over his experiences and
that having them meant he was ‘weird’ (see Table 1). However it also seemed John
made him feel less lonely and also supported him when he was having arguments
with others. His initial goals were to increase his perceived control over John from
0% to 80% and to reduce the number of arguments he had with his parents from two
big arguments a week to one small argument a week. The advantages and
disadvantages of therapy were discussed in detail, with no attempt being made by
the therapist to influence Sandy’s decision aside from listening and asking
exploratory questions. The advantages included an increase in control, more sleep,
improved mood, people not thinking he was ‘weird’ and not having a secret.
Disadvantages included fear of John possibly getting worse through therapy, risk of
losing someone important and feeling lonelier. Sandy concluded that he was willing
to take the risk of losing John in order to regain control. An initial contract of six
sessions of CBT was agreed, although he understood more sessions would be offered
if he needed them.
Formulation
Morrison’s cognitive model of the maintenance of auditory hallucinations was used
to guide the formulation and therapy (Morrison, 1998; see Figure 1). Various triggers
were identified, including falling asleep, doing mundane tasks, daydreaming, feeling
lonely and arguing with people (where John would take his side). Sandy was also
able to make John appear by thinking about him and wanting to speak to him, which
he often did. Although he thought John made him feel less lonely, he also believed
with 100% conviction that having John meant he was weird, that people would reject
him if they found out about John and that John meant he had not grown up. He also
believed with 100% conviction that John was uncontrollable and that he would have
him forever. Sandy’s positive appraisals of John made him feel less lonely
sometimes, but his negative appraisals led him to experience heightened anxiety and
loneliness at other times. This anxiety and loneliness in turn seemed to lead to an
increase in John’s frequency and duration. In response to his growing distress, Sandy
6
tried to reduce the duration of John’s appearances by either complying with him,
singing over him, shouting at him to leave or trying to push him away. These
responses were hypothesised to lead to an increase in John’s duration and intensity,
based on the underlying theory that John was in part a misattribution by Sandy of his
own thoughts, feelings and visual imagination (Bentall, 1990). Consistent with this
theory, John shouted when Sandy shouted, sang when Sandy sang and often
appeared to be in a similar mood.
Although Sandy had previously used distraction as a way of managing John, the
frequency and duration of John had recently increased to the point where this no
longer appeared to be effective. This increase appeared to be due to the gradual
formation of the previously mentioned catastrophic appraisals, which in turn led to
mounting anxiety. It also seemed that Sandy’s positive beliefs about John led him to
engage with him frequently when he was growing up, possibly causing John to
become relatively ‘encapsulated’ leading to an ‘illusion of independent agency’
(Taylor, Hodges, & Kohanyi, 2003; Taylor, Carlson & Shawber, 2007) or becoming an
overlearned and automatic ‘skill’ (Wells, 2007).
A final hypothesis was that improvements in Sandy’s sleep would be achieved by
increasing Sandy’s control over John. Improving his sleep might then reduce his
irritability and anger, in turn leading to fewer arguments with his parents. Although
there was some indication of other contextual and family factors contributing to
these arguments, Sandy did not want to focus on these. It was also hard to assess
their true significance while Sandy was still distressed, anxious and suffering the
effects of mild sleep deprivation.
Intervention
A thought suppression experiment in session 2 helped Sandy realise that trying to
push visual images away could be counterproductive (Wells, 1997, 2008), and he was
encouraged to see whether this also applied to his responses to John. He was then
encouraged to test his belief he had no control over John by experimenting between
7
sessions with a detached mindful approach (Wells, 2005) between session 2 and
session 3. He was advised to try not to engage with John and to try not to push him
away, but simply to let him come and go as he pleased – observing but not getting
involved. It was reasoned that not engaging with John would result in the experience
becoming less encapsulated over time and therefore less intrusive and
uncontrollable. The concurrent provision of detailed normalising information on the
prevalence of invisible friends and other such phenomena in session 3 led to a
reduction in his conviction that John meant he was weird and that people would
reject him if they knew about John. Both interventions led to a reduction in anxiety
and distress and a reduction in the frequency and duration of John, all of which
appeared to be correlated with a reduction in his conviction in key appraisals
concerning controllability and being different (see Figure 2).
Once Sandy’s conviction in his appraisal that John was uncontrollable decreased, and
once the frequency and duration of John also decreased, he changed his goal (in
session 4) to removing John entirely. He spontaneously stopped obeying him at night
and discovered that nothing bad happened. He continued using a detached mindful
approach and continued reading the normalising information as home tasks. Any
recurrence of John was examined using the formulation and counterproductive
coping responses such as shouting back were identified and dropped. A distinction
between being different and unacceptable and being different and acceptable was
introduced using the orthogonal continua technique (Padesky, 1994). Here Sandy
and the therapist produced examples of characters and individuals who were normal
and unacceptable, different and unacceptable, normal and acceptable and different
and acceptable. Sandy placed himself in the final category along with people from
ethnic minority groups and other people who generally encounter stigma and
prejudice from others.
Insert Figure 1 about here
Results
8
By week 6 (session 5), Sandy reported his quality and quantity of sleep had increased
to satisfactory levels. He also reported a significant improvement in his mood.
Consistent with the hypothesis that improving his sleep would reduce the family
arguments, the number of these had dropped to zero.
By week 12 (session 7), the frequency and duration of John had reduced to zero.
PSYRATS-AH results are reported in Table 1 and session by session changes in
frequency and duration of John are shown in Figure 2.
Insert Table 1 and Figure 2 about here.
By session 7, Sandy also no longer believed that John was uncontrollable, or that
John meant he was weird or that people would reject him if they found out about
John (see Figure 2). He also no longer believed that having John meant he had not
grown up or that he would have John forever. He reported being 99.1% confident he
could cope on his own, as he said he knew what to do now and could consult the
tapes and diagrams from the sessions should John return. Although we agreed this
would be a formal end to the CBT, he preferred to continue to meet for follow-up
‘monitoring’ appointments until he felt he no longer needed them. Altogether 4
follow-ups over a 9-month period were arranged (at 1 month, 3 months, 4 months
and 9 months post-therapy). Sandy was pleased he had met all his goals but was glad
to have access to the therapist should he experience further problems.
At the 3-month follow-up (session 9), Sandy reported having been badly assaulted
and robbed by a gang when he was out on his own. He had also just had a serious
argument with his parents. To help reduce his distress and help him continue to
apply the basic cognitive model in his own life these experiences were formulated
and key appraisals and coping responses discussed and reconsidered. There was no
reoccurrence of John despite these stressful events. His BDI-2 score at session 11
was 1 (reduced from 23 at the beginning of therapy) and his IVI score was 2 (reduced
from 60 – see Table 1), suggesting he held minimal positive beliefs about his
9
experiences and no negative or ‘metaphysical’ beliefs (see Morrison, Wells and
Nothard, 2002, for description).
Discussion
This case suggests that brief cognitive behavioural therapy may have been beneficial
for a person who met criteria for established psychosis but was not taking
antipsychotic medication, adding to the existing case study literature (e.g., Morrison,
1994). A trial comparing CBT to treatment as usual for this group is currently
underway.1
One protective factor for this young person may have been his lack of exposure to
public and professional stigma, although the impact of this was still very much
present as evidenced by some of his key appraisals. Another protective factor may
have been his lack of exposure to a system or model which in its worst form may
have assumed his experiences were meaningless symptoms of a degenerative
mental illness.
Although we cannot generalise from a single case, it supports the hypothesis that
metacognitive treatment strategies (Wells, 2008) are useful in CBT for hallucinations
(Morrison, 1998; see Valmaggia, Bouman and Schuurman, 2007, for another
example of metacognitive therapy techniques applied to psychosis). Although a
recent review found mixed evidence supporting a metacognitive model of
hallucination occurrence (Varese and Bentall, in press), further research examining
the acceptability and effectiveness of MCT in reducing any associated distress may
be warranted.
Sandy’s case may be unusual because he had never taken antipsychotic medication
before. As such his progress may be of more interest to those providing services
which seek to prevent or intervene early in a first-episode of psychosis. A
1
See http://www.controlled-trials.com/ISRCTN29607432
10
combination of auditory and visual hallucinations is rarely described in the CBT
literature, despite being a common occurence. CBT approaches for visual
hallucinations (Collerton and Dudley, 2004) are similar to those for auditory
hallucinations (Morrison, 1998) and Sandy’s progress illustrates this.
A recent study found loneliness led to an increased tendency for people to create
human-like agents in their environment (Epley, Akalis, Waytz and Cacioppo, 2008).
This, together with our formulation, suggests Sandy may also have benefitted from
interventions designed to directly reduce his loneliness (see Masi, Chen, Hawkley
and Cacioppo, in press, for review). Nonetheless, Sandy felt his problems with
loneliness were resolved once he no longer believed having John meant he was
unacceptable.
We also believe Sandy’s progress illustrates the practical advantages of considering a
person’s experiences in terms of levels of distress and impaired autonomy, rather
than assuming abnormality per se is undesirable. With Sandy, we tried to avoid
labelling his experiences as symptoms of mental illness. Instead, we approached
them as events which were undesirable only if they led to other undesirable
outcomes in the future (i.e., distress and impaired autonomy), thus allowing us a
degree of flexibility in the way we talked about them (Jackson & Fulford, 1997).
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Table 1. PSYRATS-AH, BDI-2 and IVI results
Measure
Pre
Post
1m FU
3m FU
4m FU
9m FU
PSYRATS-AH Distress
composite scale*
5
0
0
0
0
0
PSYRATS-AH
Frequency composite
scale**
6
0
0
0
0
0
PSYRATS-AH
Controllability***
3
0
0
0
0
0
PSYRATS-AH Total
21
0
0
0
0
0
BDI-2
23
-
-
-
-
1
IVI ‘positive beliefs’
subscale
23
-
-
-
-
2
IVI ‘controllability’
subscale
14
-
-
-
-
0
IVI ‘metaphysical
beliefs’ subscale
24
-
-
-
-
0
IVI total score
60
-
-
-
-
2
*Sum of items 8, 9 and 10 (amount of distress, intensity of distress and disruption in the preceding
week)
**Sum of items 1 and 2 (frequency and duration in the preceding week)
***Item 11 (controllability in the preceding week)
16
TRIGGERS
Feeling lonely
Feeling angry
Day-dreaming
Feeling upset
Trying to get to sleep
Doing something boring
Worrying about him
Wanting to speak to him
Talking about him
Thinking about him
Paying attention to him
Causes
John appears and sings, talks or tells me to
do things.
Increases
Increases
HOW I FEEL
WHAT I DO
More anxious, annoyed, lonely and
angry (but sometimes less lonely &
sometimes comforted)
HOW DO I MAKE
SENSE OF THIS?
Do what he wants, try and sing over
him, shout at him OR
Try and ignore him & distract myself
Leads to
Leads to
“I have no control over John”
“I’ll have John forever”
“If I don’t do what he says he’ll continue to annoy me”
“Having John means I’m weird”
“Having John means I haven’t grown up”
“People will reject me if they find out about John”
Maintains
BUT SOMETIMES
“John being around means I’m not alone”
Figure 1. Maintenance formulation of John and related distress
17
Figure 2: Change in frequency and duration of John and change in conviction in key
appraisals.
18