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Cognitive Behavioral Therapy for psychosis (CBTp)

CBT for psychosis: Agency-wide training options

Training, and ongoing consultation, is available for agencies who want to train staff in formulation driven CBTp, CBTp informed skills or a combination of the two approaches. Training modules can be tailored to the needs of the agency.

What is CBTp?

Cognitive Behavioral Therapy for psychosis (CBTp) was initially developed as an individual treatment, and later as a group based intervention, to reduce the distress associated with the symptoms of psychosis and to improve functioning. Studies have demonstrated that CBTp can result in decreased positive symptoms, improvement in negative symptoms, and improved functioning (Wykes et al 2008; Burns et al, 2014; Turner et al, 2014, van der Gaag, Valmaggia & Smit, 2014). In addition, there is evidence to suggest CBTp can be effective in preventing, or delaying, the transition to full psychosis when used with individuals identified as being at risk of developing psychosis (Stafford et al, 2013). From these studies CBTp has emerged as an evidence based intervention recommended as an adjunct to medication management (Dixon et al, 2009; NICE 2013; NICE 2014).

To learn more, download and view Routine Administration of Cognitive Behavioral Therapy for Psychosis as the Standard of Care for Individuals Seeking Treatment for Psychosis: State of the Science and Implementation Considerations for Key Stakeholders - a recent publication by SAMHSA.

We offer two models of training:

Option 1: Formulation-driven Cognitive Behavioral Therapy for psychosis

Formulation-driven Cognitive Behavioral Therapy for psychosis

This approach is provided within a therapy model typically offered in weekly sessions over a course of therapy. This training is ideally suited to clinicians who are offering direct therapeutic services to individuals with psychosis as their primary role within the service and who have a foundational knowledge, or higher, of general CBT.

Primary Objectives of Training

To ensure clinicians have grounding in CBT principles
To provide basic understanding of the general principles of CBT for psychosis
To develop competence in formulations suitable for different levels of intervention with clients with psychosis and to use these formulations to identify where to target interventions
To develop skills in developing and implementing cognitive and behavioral interventions to target positive and negative symptoms
To implement these skills in a culturally aware and sensitive manner in a community setting
To understand the role of trauma in the formation and maintenance of psychosis and interventions to address this

The training consists of a 3-5 day training (dependent on clinician skill level and topics to be covered) that includes didactics, role play, experiential learning, and clinical case discussion. Training in Formulation driven CBTp is only the first step in learning the model. Essential to ensuring sustainable and competent implementation of this approach is ongoing consultation and tape review. Reviewing taped CBTp sessions using the Cognitive Therapy Scale – Revised (CTS-R; Blackburn et al., 2001) provides clinicians with the opportunity to receive feedback on the use of the CBTp intervention that reflects the real-world application of this approach specific to the clients seen by the clinician.

Coaching to Competence Model

Weekly consultation groups comprising four clinicians per group meeting for 60 minutes a week for 10 months via video conferencing
Clinicians submit a taped session every month for competence review until clinician meets competence standard (on average six tapes)
Meeting with managers every other month while consultation is underway to address any concerns or obstacles to implementation

Option 2: CBTp-informed interventions

CBTp-informed interventions

CBTp informed interventions refer to interventions that have been developed specifically for front line providers working with individuals with a psychotic disorder beyond the traditional outpatient therapy clinic. This arose from a recognition that front line providers often have the most face to face contact with clients but typically have access to the least amount of training related to psychosocial interventions. The Positive Practices for working with Psychosis (PPP) model brings together a combination of CBTp skills that front line providers can use in their work with individuals in a variety of settings.

This training is ideally suited to case managers who are supporting individuals with psychosis and want to augment their training with additional skills developed specifically for working with this population. In addition, this approach may serve as a starting point for clinicians with limited exposure to CBT who want to develop a strong foundation in this approach before progressing to training in formulation based CBTp.

Primary Objectives of Training

To introduce the concept of CBTp informed skills
Learn the principles of the FIRST model
Demonstrate skills in engagement, curious questioning, basic formulation, and interventions for attenuated and fully psychotic symptoms
Implement these principles in a culturally competent and community based model

Training in this approach consists of a 3 day training that includes didactics, role play, experiential learning, and clinical case discussion and is followed by weekly group case consultation for 10 months and fidelity review to ensure clinicians are utilizing the FIRST skills in line with the model.

Preparing for training in CBTp or CBTp informed interventions

Both of these training models include an initial training preparation period that involves consultation with key stakeholders to ensure that the training materials fit the needs of the service and clinicians. During this consultation different potential modules will be discussed and incorporated into the training plan as needed. For example, modules may include:

Review of basic CBT skills
Working with anxiety and depression
Attenuated psychotic symptoms
Incorporating families into treatment
Addressing trauma
Working with systematized delusions
Team based formulation
Group CBTp approaches

It is important that clinicians who are engaged in the training are aware of the time and clinical commitment to the training. We can assist with discussions regarding organizational readiness and identification of appropriate staff members to participate in the training to ensure training is utilized in an effective manner.

Example scenarios for training in the different models

Scenario 1: CBTp Informed Skills

An early psychosis team consisting of a team leader, 2 case managers, a nurse practitioner, and a Supported Education and Employment Specialist. The case managers predominantly meet with their clients in the community and provide support around social and functional needs. However, they have highlighted the need for additional skills in addressing psychotic symptoms and understanding triggers for these symptoms and how the symptoms are maintained. None of the team members offer ongoing therapy and all clinical encounters are done in the community.

Scenario 2: Formulation Driven CBTp

A Clinical High Risk for psychosis (CHRp) service consisting of a psychiatrist, 4 therapists, a case manager, peer specialist and occupational therapist. The whole team attend a three-day training focusing on formulation and interventions specific to CHRp and the four therapists proceed to weekly consultation and tape review to ensure they are able to deliver CBTp to competence. Other team members join the weekly case consultation calls to engage in clinical case discussion and to coordinate around how best to support the client from a team perspective.

Scenario 3: CBTp informed skills and Formulation driven CBTp hybrid

Three fully staffed community mental health teams attend a five day training covering CBTp informed skills and formulation driven CBTp. The five days are arranged so that the whole team is present for the first (orientation) and last day of training (discussion of integration of skills across the team) while days 2-4 are broken out into two different sub trainings with therapy staff attending the Formulation Driven CBTp and non-therapy staff attending the CBTp skills training. Following the training all staff attend the weekly consultation calls arranged by team allowing for full team integration of the model and case conceptualization across different professions.

Testimonials

"Katie has provided me the most thorough consultation that I have experienced. I am really understanding the essence of CBTp and recognizing how beneficial it has been for me in my work with my clients. Katie's feedback has been clear, concise, timely and validating. She challenges me in a way that makes me feel safe to do so in front of my colleagues and is creative with her walking me through each step and providing insightful possibilities for interventions that keep me, my client and the model in mind. One of my biggest values in life is growth- personal and professional. CBTp through Stanford U and specifically Katie have been so helpful in that endeavor to grow professionally. I have even been able to incorporate some of these skills into my own personal life, which has been very helpful to me in knowing somewhat what it feels like to be on the other side. I'm enjoying this process!"

Janitzia Rodriguez, Contra Costa County Behavioral Health Services

"CBTp consultation has been an invaluable tool when it comes to mastering my CBTp technique. First Hope hosted a 3-day training and paired that with a year of subsequent consultation calls. This process has enabled me to take my previous experience with CBT and really focus on the mastery of the different components. Katie was very thorough with her feedback on my sessions and gave specific examples and real-world approaches to apply CBTp in a clinical setting."

- Brandon Frazier LMFT. First Hope

"Onsite training for the Kickstart team on CBT for psychosis was an excellent experience. It allowed those who have participated in previous CBTp trainings to be refreshed while newer staff were able to explore different forms of interventions to use with their clients. The interventions we learned not only allowed each training participant to further understand what direction to take with their clients, but it encouraged further case conceptualization as a team. Having these discussions as a Kickstart team will allow us to strengthen our communication and understanding of a case, and how to apply all of our strengths to help an individual progress in treatment."

Michael Garrett, Kickstart Program, San Diego

"Training and consultation with Kate Hardy has helped me to hone specific skills that CBTp values, such as collaboration, goal setting, and reducing distress through supporting patient’s personalized meaning making of their experiences."

Shoshana Green, UCSF

Faculty

Clinical Professor, Psychiatry and Behavioral Sciences

(650) 725-5590

khardy@stanford.edu

Bio

Kate Hardy is a California Licensed Psychologist who has specialized in working with individuals with psychosis for over 15 years in both research and clinical settings. Dr. Hardy received her doctorate in clinical psychology from the University of Liverpool, United Kingdom. She has worked in specialist early psychosis services in both the UK and the US, including UCSF’s Prodrome Assessment Research and Treatment (PART) program, where she completed her post-doctoral fellowship, and as Clinical Director for the Prevention and Recovery from Early Psychosis (PREP) program. Dr. Hardy has significant experience in providing CBTp to individuals with early psychosis, and those at risk of developing psychosis, in both individual and group settings and integration of this clinical intervention to broader systems and staff teams. She has led multiple trainings and workshops in CBTp to a wide variety of audiences including community clinicians, psychiatrists, and families, and provides ongoing supervision and consultation in this approach. Dr. Hardy is also involved in the implementation of national strategies to increase dissemination of early psychosis models with the aim of bringing these cutting edge treatments to a broader population.

Clinical Associate Professor, Psychiatry and Behavioral Sciences

Bio

Dr. Eisen is a Clinical Assistant Professor and CA Licensed Clinical Psychologist working with the INSPIRE Clinic at Stanford. Her research and clinical interest center on therapeutic interventions that support recovery for individuals living with serious mental illness, in particular for individuals with psychosis. Dr. Eisen received her bachelor’s degree from Cornell University, and her PhD from the University of Connecticut, and completed postdoctoral training at Stanford University. Before coming to the INSPIRE Clinic, Dr. Eisen worked for over 10 years as a psychologist on the acute inpatient units at Stanford Health Care. Dr. Eisen is trained in CBT for psychosis (CBTp) and has worked with colleagues to train therapists, nursing and multidisciplinary staff, medical students, and residents to integrate CBTp informed, recovery-oriented approaches into their work with individuals with psychosis. She provides both individual and group-based cognitive behavioral therapy.

Clinical Assistant Professor, Psychiatry and Behavioral Sciences

Bio

Dr. Nichole Olson is a Clinical Assistant Professor and licensed psychologist in the INSPIRE Clinic and Dialectical Behavior Therapy (DBT) program at Stanford. Dr. Olson completed her masters and doctorate degrees at Northwestern University in Chicago and finished her postdoctoral fellowship at Stanford University. Dr. Olson specializes in evidence-based, recovery-oriented care for individuals with psychosis, providing both individual and group Cognitive Behavioral Therapy for Psychosis (CBTp) to adults within the INSPIRE Clinic. In addition, Dr. Olson leads trainings and ongoing consultation for providers learning to implement CBTp. As a clinician and Assistant Director of Stanford’s DBT program, Dr. Olson also provides individual DBT treatment for those with emotion regulation difficulties.

Contact Information

More information: Dr. Kate Hardy at khardy@stanford.edu

Current and past training contracts in these models include:

University of California, San Francisco
University of Pittsburgh Medical Center
California Department of Corrections and Rehabilitation
Department of State Hospitals
Michigan State/Network 180
Contra Costa County Behavioral Health
Santa Clara County Behavioral Health
Stanford Health Care Psychiatric Inpatient Unit