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Psychotherapy and Applied Psychology
Psychotherapy and Applied Psychology is hosted by Dr. Dan Cox, a professor at the University of British Columbia.
This show delivers engaging discussions with the world's foremost research experts for listeners interested in or practicing psychotherapy or counseling to provide expert insights and practical advice into mental health, psychotherapy practice, and clinical training.
This podcast provides valuable insights whether you are interested in psychotherapy, an applied psychology discipline such as clinical psychology, counseling psychology, or school psychology; or a related discipline such as psychiatry, social work, nursing, or marriage and family therapy.
If you want to learn about cutting edge research, improve your psychotherapy/counseling practice, explore innovative therapeutic techniques, or expand your mental health knowledge, you are in the right place.
This show will provide answers to questions like:
*How will technology influence psychotherapy?
*How effective is teletherapy (online psychotherapy) compared to in-person psychotherapy?
*How can psychotherapists better support clients from diverse cultural backgrounds?
*How can we measure client outcomes in psychotherapy?
*What are the latest evidence-based practices?
*What are the implications of attachment on psychotherapy?
*How can therapists modify treatment to a specific client?
*How can we use technology to improve psychotherapy training?
*What are the most critical skills to develop during psychotherapy training?
*How can psychotherapists improve their interpersonal and communication skills?
Psychotherapy and Applied Psychology
Treating Psychosis with Talk Therapy with Dr. Mahesh Menon
Part 2 with Dr. Mahesh Menon, clinical associate professor in the Department of Psychiatry at the University of British Columbia (UBC).
Join Dan and Dr. Menon in part 2 as they continue into the complexities of cognitive remediation and its application in mental health, particularly in psychosis. Dr. Menon discusses the cognitive challenges faced by individuals with psychosis, the importance of metacognitive training, and innovative approaches like avatar therapy. Dan and Dr. Menon emphasize the need for personalized treatment strategies that address cognitive biases and enhance patient insight, while also navigating the pushback against certain treatment modalities in the mental health field.
Special Guest: Dr. Mahesh Menon
Cognitive Remediation Resources
The North American CBT for psychosis Network page
Links to a lot of helpful resources (video, books etc) related to psychotherapy for psychosis
Online Training Portal for Metacognitive Training (MCT) for Psychosis
Brain Fitness Games
Dr. Nicola Wright: Resources for treating psychosis
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🎞️ Video version of the show@PsychotherapyAppliedPsychology on YouTube
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Connect with Dan
☏ Leave a voice message on Speakpipe
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[Music] Broadcasting from the most beautiful city in the world, I'm your host, Dr. Dan Cox, a professor of counseling psychology at the University of British Columbia. Welcome to psychotherapy and applied psychology, where we dive deep with the world's leading applied psychology researchers to uncover practical insights, pull back the curtain, and hopefully have some fun along the way. If you find the show useful, be much appreciated if you shared it with someone who might enjoy it too. Today I couldn't be more excited to welcome back one of the world's authorities on psychosis. In this conversation, we dig into the several treatments that he has been a part of. And by the end of this conversation, what I was amazed by was the similarities between what therapy for psychosis and what I think of his typical therapy looks like. And in a lot of ways, I left this conversation feeling like therapists who are interested in working with psychosis, how short that distance really is. This episode starts with my guest talking about cognitive remediation for psychosis. So without further ado, it is my pleasure to welcome back my very special guest, Dr. Mahesh Manan. CR, like cognitive remediation itself, you know, came out of like a, the, I think the brain injury world at some point, there was a wild back with like, rheumatial, the sort of hype that maybe kind of doing computerized brain exercises could like help with like keeping your brain sharp, maybe prevent a client and so forth. And some of that hype didn't really completely translate into like prevention. So now, certainly like, when we think about it in the context of psychosis and kind of mental health disorders, with psychosis, there is no part of the brain which is damaged. There is, you know, some idea that maybe different parts of the brain are kind of talking to each other in a somewhat inefficient way. Maybe there is kind of disconnectivity between parts of the network or the networks are not kind of shifting as they need to quite efficiently. So we can think about in the context of psychosis and maybe other, you know, like depression and ADHD. And so as like related to an intact brain which is where parts of it are not functioning as efficiently as they should. So I think within that particular context, it might be helpful. And so now like CR, there was a great white paper that was written by Chris Buie, Mattel Weiss and a lot of the sort of world experts in in CR. And the idea they said was that like, when we think about the components of effective CR, what we need is one is the person to understand like, okay, what is happening for me in terms of cognition. Subjectively if you ask them, everyone will say, oh, my memory is not very good. But what their experience in could be kind of due to, you know, intentional issues could be due to kind of consolidation, it could be due to the like, the memory of retrieval, it could be due to the executive functioning challenges. So certainly, the clinician and the client kind of working, you know, to understand like, what is that cognitive profile looking like? Where are we seeing areas of challenges one? I think then having these computer programs or kind of paper and pencil things to like kind of stimulate your brain. The hand-waving explanation we're going to use for that is like, it's fostering your plasticity in some ways or kind of increasing network efficiency within our brain, right? You can do kind of harder cognitively challenging tasks. But alongside that, we also are trying to develop the medical cognitive awareness of like, where am I running into problems with the task? Can I use strategies to enhance my performance in that task, right? And so that strategy awareness, strategy utilization, and then the generalization from that computer task into daily life activities. So those are all the components of an effective CR intervention. So it's really dealing with that when you're laying out sort of the four, I don't know, symptom clusters is how you want to organize it. But the four sort of big picture challenges the folks with psychosis have, this is on the cognitive side. This is sort of mental functioning, the stuff that everybody has every day, the stuff that's going to show up, that's going to be related IQ, that's going to show up in tests, that's going to show up just in when you're playing a board game or when you're, you know, all that cognitive, this is addressing those limitations that folks with psychosis often have. Yes. And so, you know, the data around cognitive functioning in psychosis finds that they are across the board of parents in cognition, but some of those are like much more significant. So for instance, when we look at verbal memory, the metanolacy suggests that, you know, it's between two and three standard deviations below the mean, right? For executive functioning, it can be kind of between one and two standard deviations, processing speed is between one and two standard deviations. So these are really quite big, you know, impairment cycle scene. And then those challenges, they, we think that they're sort of a two step process that's happening. So we start to see some kind of declines in cognition that are happening kind of in the pro-dromocase prior to the onset of the psychosis and then within the first few years of the illness as well. And then it sort of platoes out, but then it's like a two-hit decline that has happened. And the curse of the age of which it happens, this is often when people are in high school or kind of just finishing school, you know, trying to get there, you know, either kind of going to university or or or find a job. And so those really key life transitions have now been impacted. And you're going to risk, you know, someone who then also is dealing with these really kind of experiences of, you know, lack of success, defeat is beliefs, shame, that's associated with that. And then coping with all of those with isolation, like I don't want to try these things, it's just too hard for me to do, right? So in some ways, finding ways to not just like improve kind of cognition on some computer tests, but really kind of helping people to say, how can I bring these into the real world and also embrace the challenge of doing things which are harder to do can be helpful, not just with the cognitive symptoms, but we also hope that some of those negative symptoms and defeat us, believe it's at the person, I'd hold it as well. So, right, because these are folks who, you know, by and large, you know, so if we think of an illness as an oversimplification, but if we think of IQ as relatively permanent, that a person who has, you know, somewhat below, lower than, you know, lower than average IQ, that they've had that more or less their whole lives, and that they've, you know, in, you know, optimally, they've developed strategies or other people have helped them develop strategies to be able to still solve the problem, whatever it is, right? But for these folks, what you're, what I'm hearing you say is, right as these people are getting into, you know, early adulthood or, you know, the late teen years, what, that they're functioning all of a sudden takes a nose dive, right? Which you can imagine, which I would imagine is, in some ways, there it is a lot more difficult than if it's always been that way, because then it's, I mean, we've all sort of been there, right? Where, you know, I just recently took skiing back up again after, and so after about a decade off, and so, you know, it can be very frustrating because you're out there and you're like, I used to be able to do that very difficult thing, and now it's I'm struggling with an intermediate thing, right? So that's, and it's a very different experience. It's a frustration at yourself, and that I could see that how that could, getting back to some of those negative symptoms, how that could lead a person to feel like I'm falling apart. I used to, I used to, like, I used to just be able to do this, and they never had to develop those skills because they could just, the brain just worked better. Yeah. And then if you've been overwhelmed with, you know, the, let's even think about a social situation, right? You're in a social situation, and people are talking, and you're trying to remember what people are seeing and shift your attention across different things that pick up on social cues, and all of a sudden, you're overwhelmed with the amount of information that's coming to you, you're not processing it at that same speed, you're not remembering it as well. Your ability to function in those social settings also kind of will decline. It makes sense that you might cope with it then by saying, like, I'm just going to avoid those social situations altogether. Then even the social skills that you do have then become a little bit rusty-er, and at that same time, you might also be dealing with, you know, hallucinations, which if you've ever kind of had feedback on your headset while trying to talk, it is impossible to actually say anything while you're also hearing something else. It's so profoundly impairing. So, you know, there's just so many things that are happening. So anything that we can do to kind of improve function, like the cognitive end of things can make it easier for them. So there are these two very different approaches towards CR1, says that, you know, like that, the initial data that's coming in sort of a bottom-up approach is a little bit messier because of all the other factors. And so they are doing like really kind of simple like tone differentiation, kind of like improving visual processing, whereas I think the approach that I, we have preferred using has been kind of a more popped-on approach. So using a more like medical and perspective like, okay, here is the task that I want to do. How can I use strategies to manage those? How can I notice when I'm running into difficulties and kind of overcome those? When do I need to pause? Take a break? Go back to it. And that sort of thing. Can you give us either an actual clinical example from something that you've experienced or something made up that would sort of like align with a clinical, like something specific, like how that would, how that might play out in real life. So we, I mean, so CR is, you know, it's been, it's been well established enough. And so what we have actually been doing in BC is that we've been, we got some money from the Ministry of Health and we are rolling out a pilot project trying to embed CR in routine clinical practice. So one of the really nice things from it is that we've gotten so much wonderful feedback from the clients who've been, you know, doing the groups and then, you know, so like a young person who had like a first episode of psychosis, they dropped out, they were kind of in school and working part-time. And they dropped out of school because they weren't able to kind of cope with those pieces. They weren't able to work. The anxiety of those things and adds another layer of challenge to it. So they're in the CR group. They're practicing these computer exercises, but more than that, they're also bringing those strategies to daily life tasks. And we talk about the idea of embracing cognitive challenge. And so certainly this approach to CR uses, embed some of the sort of psychotherapeutic elements in there as well. It's not really just kind of rounded that the cognitive remediation piece it is also about like how do we kind of get you out into the real world and doing stuff. So what is like, like what would be an example of a computer task? So a version of a computer task might be like in the executive functioning one, there is a version which is like the towers of London. The task if you've ever seen it. So you've got these rings and you have to kind of move the rings to kind of stack them up in a particular order in the most efficient way. But like we have a version of memory task. There is it's a restaurant game. Right? So you're shown a table and there's kind of seats around the table and there is you're told to imagine you're a server at a restaurant and there are people sitting and they'll give you their order and you have to remember who got what. So it may start off with like two people sitting on the table and each person orders two things and then you see like a number of dishes that will flash up and you're like was that one of the ones that I saw who should I give that order to? And then it may be like there are those and then there's a distractor. So it's like oh no that's not for my table that's for someone else's table right? So that's the next level of challenge. Then you may have more dishes and two people then you may have four people and then more dishes and then the people actually move seats so you have to now remember the names of the people and where they have moved to as well so it's not just kind of like the spot. So the the task gets harder and harder to do and the approach that we use so we use an approach to see our action-based cognitive remediation which is developed by my colleague Chris Bowie who is at Queens and they use a software from a company called Happy New Year on and the the approach to the computer games itself uses kind of what's called airless learning so you have to get perfect on one level and then you bump up to the next level and then you so you're trying to use the strategies to kind of get that level of challenge and then you can bump up to the next level and so I think for a lot of people who get video games on the gamification part of it that's quite appealing to them so you know you've got one and then you're moving after the next level. And so a lot of the the group work that you're doing with patients is to help them start to see the links between what they're doing in these computer games these that are sort of pushing them cognitively but in this obviously you know necessarily restrictive context and start to see right because if you're not a server the seeing the names or whatever isn't but then if you think about yeah so but when you're in this class for the first time and you introduce yourself to the person sitting here there and there and then the instructor introduces themselves that how can we use those strategies to help me remember those four people's names as well particularly since three of those people might sit in different seats next week or might wear different clothes or whatever so you're helping to bridge those gaps. Yeah and in this particular approach to CR the action-based part of it is actually that in session in addition to doing the computer exercises there are these versions of real world so like the neo-transport task so real world activities that correspond to those skills and strategies that we're doing on the computer games. So for that memory one like the memory exercise that we do the real world one is everyone around the table actually gets a little piece of paper and so you're told like you're at a new job and you're meeting a bunch of your co-workers and each person kind of reads out something you know my name is X I'm from here and I collect old records or whatever like you know different piece of information and then we're trying to use visualization and the monics and kind of just more complex learning strategies to try to remember that information and then people kind of go around and practice like how much did they remember about the other people what strategies did the did my did the other person who was in the group with me used were they able to better remember it and then we may use the homework exercise might involve doing the computer activities as well as using those strategies to try to remember stuff in real life or like I'm going to go grocery shopping and I'm going to try to not remember to look at my list till the end but I actually try to remember all of those through like men you know the recipes that I'm going to make maybe things which are in the island using visualizations or kind of like different strategies and then the clinicians also work with them to link those towards the specific goals that they themselves are working on in life. Got it got it yeah that sounds I mean that and you can just imagine all of the whether there are going to be certain group effects that are happening which is one that you're going to say like oh I'm not alone in this yeah you're going to say that okay you know it seems like I really struggle in this but when I look over you know Susan she really struggles in this other thing that I'm much better at and John he really struggles in this thing that I'm much better at so I help them they help me so just you could see a lot of those you know the therapeutic benefits happening. Yeah and the sense of community and the normalization as well as kind of again like if if they can kind of cry this maybe I can also take on this challenge that's sort of the afternoon as well. Right right okay so what makes sense just jump to the meta cognitive training. Absolutely. Okay so I think this gets a lot back to what we were talking about earlier but so can you give us a 30,000 foot of what meta cognitive training is. Yeah so kind of in the late 90s in the early 2000s sort of when I just started off with some of these questions for myself, some of my colleagues so two of them taught Woodward who's here at UBC and Stefan Moritz who is a psychologist from Germany who had come here to Vancouver you know had also been kind of looking at these same questions and a number of people like in the UK have been looking at cognitive biases so are there biases in how we're kind of processing information that are associated with delusions. So one of the ones that I've been talking about PhD was like you mentioned kind of the source monitoring but the one which is the most specifically associated with delusions was one that was called the JAPID conclusions bias. So essentially the idea is that even in a neutral setting which has nothing to do with delusions people who are prone to delusions might be using less information to arrive at the decision. So we the simple task that I had used during my PhD that's been used to punch is just called like the beads tasks so you have these jars with beads so let's say there's like two jars with a hundred beads in each of them and it's like 80 red 40 blue and the other one is 80 blue or sorry 80 20 and the other one is 20 80 right and you're told I'm I'm going to put it the later one of the jars and I'm going to take out the beads one by one from the other one and I want you to tell me when you're sure which jar you think I'm taking the beads out of. So you just kind of pick them out one at a time and then the person can like say I'll like to see more or I know which one it's from and so it turned out that like so with the idea just to real just to so the idea being that if you have it's if you had the jar that it's 80 blue 20 red and you picked out a bunch that we would expect that that's going to be the blue jar if it's mostly blue ones. Exactly. So it was like blue blue blue red you're like oh it's the mostly blue jar right. Got it. So it turns out that about 40% of people with delusions would make a judgment in like one or two beads and that amount wasn't varying because like 80 20 versus 60 40 like even as it becomes more uncertain you're not taking more information into account. So I mean the apart of why we're doing this task is because in real life it's hard to know how much information am I using to come to a decision under conditions of uncertainty. So what we're trying to do is look at probabilistic reasoning under varying degrees of uncertainty and to quantify the number of pieces of information that you're using as well as how much is your certainty increasing when something fits with your hypothesis and how much is your certainty decreasing when someone when something doesn't fit with your original hypothesis right. So so thought I developed this idea like so we call it like kind of a high per salience of evidence hypothesis matches where if there is I think it's blue and then I see a blue and my confidence in it is so much that it kind of crosses that confidence threshold. I'm like I know which one it's coming from. So the interesting idea that God and Stefan had and Stefan's really run with this a lot and done so much work on this was he said like let's take this and let's make it a clinical intervention. So it was a knowledge translation exercise like you know we would talk about this in like you know public forums to army members and like client groups and they say oh my god I totally see that I do that and I love to undo that thing. And so we took all the research around the cognitive biases which were thought to be associated with delusions and then made kind of an experiential activity where like you know you're like one of the exercise we do is like I'm going to show you a picture and what you tell me as soon as you know which what the picture is up we're going to see parts of that picture and then you know people can play and it's a game and it's fun but we're trying to socialize people to that idea you know look if you guess too early you're getting it wrong if you wait too long yeah sure it's you know you've probably waited too long but there's a sweet spot and there's times when you want to make a quick judgment and times when you really want to slow down and when we're stressed out or we're anxious but prone to jumping into conclusions so how can we kind of slow this down. So it ends up being basically a way of getting people to become aware of the cognitive biases that they may engage in so the big ones that run through it one is to slow down and like not be jumping into conclusions and the other one is basically a very reliable bias that we found was called the bias against disc and vermetory evidence so all of us look for evidence that fits with our existing beliefs so we look for confirmatory evidence but if we get disc and vermetory evidence we are probably able to hear that and accept that to varying levels the stronger the belief the harder it is for us to take in disc and vermetory evidence but that is even more pronounced with the notions and you can see that is a maintenance factor right like we're getting all of this information that says this is not true but not able to kind of integrate that effectively so how can we kind of help people learn how to better look for disc and vermetory evidence and integrate it that themselves so those are like the two themes that run through it slow down look for more evidence and look for things that don't fit with your belief and consider alternative explanations so in group or we say to people like what's the boring explanation that has nothing to do with anyone trying to harm your mess with me and how can I kind of look for anything that shows maybe the boring explanation is true right so we there are modules that look at genetic conclusions and the spade bias as well as emotion recognition memory biases and then some of the more classic biases that we see would like depression right the all or nothing thinking and so forth so there's it's a series of modules it's a very structured intervention there's a lot of CBT components which are present there as well so we joke that it's kind of like CBT through the back door right we're not talking about your delusions and your thoughts and so on but we're really saying hey look at this bias that we all fall prey to and really normalize that experience and then say as a homo case size why don't you think about how this plays out in your day-to-day life and and so get people who may not be wanting to talk about their beliefs or delusions to still be able to engage in a sort of therapeutic group discussion about that so it's so really to think about this these are these are biases that we all have to some extent or another it's but for folks who have delusions on average the volumes turned up on a handful of these biases so let's just attack these biases specifically through while also normalizing in the same look we all right you know have this right but we can all do better when we're stressed out right you're dealing with paranoia the more paranoid you feel maybe the more prone you are to like thinking you know in the sort of like you know thinking fast and slow way we're kind of using not are like kind of slow rational system we're just kind of jumping to these conclusions how we slow down process ourselves to kind of consider these alternative explanations so this is this is attending to perhaps even attacking some of these biases but this sounds like it's also could also help facilitate patient insight yes and we can so you know we were talking about that idea that insight is not a unitary construct right so we can still think about like someone can have insight into having a diagnosis someone may have insight that medication helps me with my anxiety someone may have insight that this belief is a delusion right that's a kind of a much more nuanced one but yeah we're trying to like help people is a more kind of like just a metacognitive awareness of hey I'm jumping to conclusions here I'm making that assumption that that person was looking at me because they wanted to harm me right I might not get to like that as a delusion or I have psychosis where it's kind of sidestep in that question altogether but we're just saying can you recognize that on a moment to moment basis these the tendency to kind of fall into these thinking traps makes us feel anxious and unsafe and if we can notice our thinking trap and sidestep it then we feel safer in the world so like in the case of that person is looking at me they might they want to harm me it would be to help the person to slow down and say okay they're looking at me which might mean something it might not what other evidence what I need yes support my thinking that they want to harm me right and then to appraise the situation yeah more generally well would would would if this person wanted what would be he's with his kid what would be the odds that somebody wanted to harm me would be with their two-year-old when well it seems like that would so like to just engage in some of that yeah and so you know in some ways ask people kind of get into that you'll see the overlap so like you know so far like reasoning as well but we are just trying to kind of come out of from just like getting people to use the little like oh I'm doing that thing right our little heuristic about our heuristic if you will like it's just yeah okay so so now so cognitive remediation or I'm sorry cognitive behavioral therapy for psychosis yeah so how does that differ from metacognitive training and from the cognitive remediation yeah so the CBT I mean the CBT for psychosis really is is very similar to like how we might think about CBT for depression or it's okay right we are socializing people to the model of like recognizing like my thoughts these are my thoughts this is not a fact this is just my thought right my thoughts can be biased by my emotions state how do I look for evidence in favor of my thoughts or evidence against my thoughts how do I test out my beliefs you kind of do the behavioral experiments how do I how can we kind of develop a longitudinal formulation in therapy around like how do people's life experiences shape the kinds of thoughts that they have how do what makes us more prone to thinking that maybe in harm's way right so kind of going back to the experience that I used there is data suggesting that you know bullying and early latrometer actually is again a huge risk factor for developing pionary and voices and so forth and when we think about it just you know like there's face validity to the idea that if I thought like if I was bullied then there was a period of time where a number of people were trying to harm me right they were looking out from that they were looking for me right and if they found me something bad could happen so it kind of makes us hyper vigilant to the world around right and if we carry some of those core beliefs something triggered it at a later point the specifics of the belief is no longer that oh yeah this is the the sort of echo of that trauma that I dealt with and the people who bullied me then but we just think like well I need to be on the lookout because powerful forces are conspiring to harm me if they're given a chance right so so we can kind of see some of the elements of what will become the components of the delusion but it is kind of put into a very different narrative structure okay so shall we jump to avatar therapy yeah okay so that's what you're doing now so I you know and that's what you're in the middle of this is a little bit more you know I think the other the three other sort of treatment approaches are much more been around for a while a bunch of evidence supporting them tweaks that are happening that are wonderful where the avatar therapy is one of the the new exciting areas that you're working in yeah so again like there was some wonderful work like this is developed by a group in the UK and I was a psychiatrist named Julian left and two psychologists and warden and a locality and this comes from slightly slightly different approach towards treating voices which basically says like voice hearing again there is the sort of trauma lens and that part that you know our life experience is kind of shape what the voice says right if people have dealt with trauma when growing up the voices might be quite critical and kind of echoing those same you know themes if you will and then also the idea that that there are these um power imbalances between the voice hearer and the voice itself the person who's hearing the voice often feels powerless the voice feels like it is omnipotent um that is omniscient like it knows everything and can do anything to harm you and we're trying to find ways to kind of you know reduce that power imbalances well and there's also this relational approach right how do we get to be in relation to the people around us is also um echoed in how we are with the voices just to stop your old fast mash as you're explaining this one thing something about is is in you know television or movies or whatever where there's that point where the the protagonist is you know they they meet some challenge and they fail and then are there about to go and meet the challenge and there's this you know these voices in their head of their their the person who bullied them or their their mean parent or their partner who left them saying you can't do this you can't you know that like that's uh that sort of was i mean obviously that's a sort of a version of it but that's what i'm thinking about as you're describing and and you know if we just think that like we could see that and we may have those as thoughts but then the additional barrier for someone who's experiencing voices they may hear a voice which doesn't sound like any of those people so they're not even able to say oh yeah that is that fear that i carried with me right but that it sounds like someone completely different saying you're going to fail at this task or something bad will happen to you if you kind of get out and try to do this thing um and they're not able to kind of connect all of those thoughts so um the idea was that um if you could create an avatar that sounded like the voice that the person heard and for people who have a very clear picture in their head of like this is the voice you know it's you know the voice is Bob he would be used to be my neighbor this is what it looks like this is what he sounds like this is why he's doing this thing to me so that propianing example of a well characterized voice and the idea was that if you can create an avatar of the voice then you can kind of use say some of those like kind of assertiveness and self-compression skills to just be like sound of how do you want to respond to the voice in a way that feels true to you that you feel good about and they can practice and they can actually respond to the voice in that way so it starts off with the therapist just basically obey them saying what the voices have been saying to the client and so just to for the listener when you say avatar you literally mean a computer generated yes sorry yes so what so there are some pieces of software now that are available that will allow you to kind of like create the face and you know skin tone, face shape, hair color and so on to look a little bit like the person imagines the voice to and using a voice morph to like kind of increase or decrease the pitch the sort of prepple wobble and so on and like is it usually well patients usually be like Bob my neighbor or will it be more generic but they can describe okay it's a man he does have dark hair he has yes this sort of a look and then he can work with either the therapist or technician with the software to help develop an image of that I don't know non-specific yeah so so the the clearer the sense that the person has of what the voice looks like and sounds like and why they're doing the things they're doing the more you know clear target that we have for treatment so this approach therapy is it's really helpful for people who have a dominant voice which they have these kind of beliefs it out right and so so we we work with them to like build that avatar on the computer and the study that we're doing we're actually doing a BR version of it so then they put on a BR headset and they see that that that figure and we can kind of have the figure in kind of different settings so like a living room or on a bus and then the mouth moves as the therapist speaks and the therapist can switch between being the therapist so sounding as they would and then you press a button so they sound like the voice at the person here so when we're building the avatar we're like what does the voice sound like to you and we kind of practice that and then we know what the voice has been saved them so let's say the voice says I'm going to hurt you if you go outside and and and they see it in the living room then you know we've kind of practiced it and then we might kind of practice a certainness with them we might say how might you want to respond you know what would make you feel more powerful and in charge and so then the person can be in the BR set up see the the figure as they imagine it it says you you know I'm going to hurt you if you go outside the person practice is saying well you know what I think I'm going to be okay I'm going to push myself to go outside anyway right and they practice doing that a few times they might try it in different ways to find a version that feels authentic and feels assertive for them we record those interactions so that they can listen to it when they actually hear it outside of session as well and then it goes from responding to the verbatim voices to try to build a conversation hopefully with some of the folks where it would be that you know we can understand like there was a time you're like well maybe you felt unsafe and you didn't feel like you could go out but now that's no longer true right so they could have a a corrective experience with the with the avatar that they may not be able to have with the voice that they hear right because the therapist can kind of guide that that interaction so there was some there were a few really good studies I've put down in the UK I mean it's such a kind of cool sexy idea like that now there have been other studies which are happening as well there was a recent big trial from a Danish group that had come out and the studies found that this was really effective for that subgroup of people who were dealing with the dominant voice and people felt much more empowered and and it reduced the power that the voice had covered them and for a subgroup of people because that power went away the voice intensity itself kind of diminished so that they didn't hear it so it was a really small subgroup but for some standard proportion of them they just felt empowered and able to be like oh yeah those are just the voice I don't need to listen to it I don't need to have it control my life and so that's kind of what we hope would would happen and so the therapist they're I'm assuming that not so this happens over a series of sessions this happens over a series of sessions and actually the the part where they're doing the dialogue with the avatar is actually just a small part of it outside of that in each session we are you know helping early on kind of working around assertiveness and self-compassion and how would I want to respond later on we might be kind of building out a little bit of a longitudinal formulation with the person helping them to understand kind of how life events can shape core beliefs and how core beliefs can be kind of reflected in voice content we might work on self-compassion and how might we be kind to ourselves the way we are to other people because that is often so hard for actually so hard for many of us and we can be much kinder to other people who might say oh my god I don't think I can do that you might say no I totally think you can but you know for ourselves we just it's a double standard so building that self-compassion so that people can not be taught to themselves more kindly is also going to be reflected in how the voice is speak to them because really what the voice to say is a manifestation of those core beliefs and the beliefs they may hold about themselves so outside of the voice dialogue we're doing all of those pieces and on a voice dialogue is like a small part of the session itself and thinking about you describing the the communicating with the avatar it seems like it's hitting on at least at least sort of two levels so one is helping the patient speak back and sort of interact in effective ways with the with the voice right in those moments one the voice but it's also dealing with as you said the voice please correct me but is a manifestation of some of those maladaptive schemas or whatever so you know you're you're also in pushing back against those beliefs that it's certain things are unsafe that actually are aren't unsafe put you're also sort of pushing back on that like not just the voice but on your own belief you're sort of doing I mean in my way you're doing like a cognitive therapy on yourself totally you're getting at you're getting at the core beliefs themselves right and and the therapist is really kind of guiding that that process so so the first trial that was done avatar one they used a very brief like six sessions where they just got people to learn to stand out to the voice itself without getting to those other pieces and they found that that was quite effective and then they did another trial so avatar two which was twelve sessions long where the first few sessions were put that part of like kind of stand up to the voice stand up for yourself and then the second half of it was kind of like building on some of the pieces of like in longitudinal formulation and that was even more effective in the longer term and what we've been wanting to do is really kind of integrate some of the components of like compassion focus therapy and and act right and kind of bring that into the the dialogue we have with the clients and hopefully reflected in the dive in the voice dialogue as well so we are kind of building on the work of avatar two but kind of taking the therapeutic approach so my colleague Nikola Wright who's based in Ottawa had written a book called treating psychosis which integrates CBT with CFT and act and so we're using kind of that framework of like this this very integrative therapeutic approach. And you know actually it's funny you went there because as soon as I said you're sort of doing this the person's doing their own sort of CBT I immediately thought well that's sort of that could be one way to think about it but another way to think about it sort of like from an act perspective could be that you're creating like it's you're dealing with this cognitive fusion so right so you're sort of separating yourself from this these thoughts or this voice which is you know and then you're able to move forward consistent with your own values despite that voice sort of going off right next to you or even from a psychodynamic right you're dealing with this interpersonal dynamic that you have with this voice and like you're able to have this interesting you're able to you know work on sort of that power structure and you know all those and think about how it relates to you know sort of those early life childhood experiences or you know or whatever it happens to be changing the buttons that we might be kind of locked into in some way yeah totally yeah so I think that it's it is yeah I sort of always try to move away from thinking very like I sort of think that thinking about therapy as a you know we all sort of tend to need like a specific approach to have a but that these things are much more pan theoretical and that the approach that you're using could be applied from practitioners to use all sorts of orientations yeah and and I think you know we that it's those it's many parts of the mountain right that lots of time to start to see kind of some techniques which will overlap with others but also sometimes you know you'll be pulling some tools from one and several of the other but hopefully there is a formulation or a rationale for why you're why you're applying those techniques right as opposed to right so one question I always ask folks is if they've had and various people's responses if they've had any pushback to their work yes I mean I think that so well certainly in psychosis because of you know what you will either do that there are some quite strong you know movements or forces right so you know in our discussion I've certainly been privileged to kind of work with a number of amazing colleagues who are all thinking about the illness at sort of different levels less the sort of biological level there's the psychosocial level there is the kind of social systemic trauma piece as well but you know we can have people who sort of like lock into one camp right there is like the people who are like this is a biological illness we treat you with medication and that's it right for many years people wouldn't talk about the person's own experiences like the the dog onwards you don't talk about deductions because you will kind of reinforce it so they didn't right and so we're sort of saying no no therapy plays a huge very helpful part in the recovery process it's really meaningful want to help people understand why they have certain experiences and really kind of engage with them around the content of their deductions and hallucinations and I think that is kind of one you know piece that we're you know sort of changing I wouldn't say that's pushback but I think it's like correcting a belief certainly within a very biomedical model of the role of the importance of therapy in the treatment of severe mental illness and on the other end of it I think that there are people who have quite strong like anti-secretary you know idea that like look this is just like a way of coping you know like it is like this imports the same coping in an insane world right idea that like this isn't an illness this isn't anything which requires treatment we should be kind of free to have those and so sometimes I think you know we're also saying no like I think structure treatments hospitalization medications can play an important part in the recovery journey for some people right and and so I think that I'm sort of correct straddling both where I'm saying no we want to understand the personal meaning of those experiences but we also want to recognize that it is getting in the way of like functioning it is causing distress it is causing impairment and we need to kind of address it we need to use the tools of science and we need to kind of like say like this is kind of what the evidence is suggesting right and I think there is a little bit of like sometimes I think pushback against against some of these these interventions I can all right that is the pushback that type of pushback is that more from people inside the field or outside the field so some can it can be like some can be people who've had like very difficult experiences you know may have had an experience of psychosis and may have been kind of involuntary hospitalized right and they might see like you know like there are like patient advocate groups which really kind of our passion for that and I think again like having a having a very kind of compassionate name perspective or like how can we make treatments better how can we kind of reduce the sense of parallelism as that people are experiencing in in that really difficult period in their lives I think is is really important and the system isn't always getting right now and I was going to say when when you said that that all of a sudden it sort of clicked for me because I think I've sort of talked to some folks recently who've sort of had experiences with let's say unpleasant hospitalization and it's sort of like you know I get that like I understand how a person gets you know they get hospitalized they don't want to be hospitalized or they're fine with it but then their experience is awful and that that I don't it makes sense to me it's unfortunate but makes sense to me how then they just sort of become you know loose faith in the whole system or and everybody and certainly like I am someone that's in that system right like I I work at the hospital I run this provincial pilot program within I am in the psychiatry department as an academic you know so definitely in the system but I do think that's like that's that's kind of how we want to be able to like embrace all those perspectives and really kind of it's a movement who is kind of creating the most humane compassionate kind of approach to treatment yeah I think I've had some interactions with folks not not who fall in this category not who fall into folks who've been hospitalized and had difficult experiences but sort of folks who are outside of the mental health space if you will and to sort of our and who push back against having in patients you know for psychiatric disorders and the sort of thing and I sort of oftentimes I sort of just you know it's just sort of like if for those folks it's like you don't know you haven't had this experience like when you work with these folks and you know fortunately it's a very very small percentage of people but that folks who are really struggling with severe mental illness that they need serious help because there's just they just you know their life is hard and their experience of reality is very different than ours and yeah and of course you know like they're again I kind of creating an environment which is sort of safe with them but also safer the people that are around them absolutely comes really really important right and I think that's I got fortunately it's also that those those are the things which kind of hit the news a lot right and cause sort of polarization right when yeah yeah this person has psychosis and they've done something heinous and yeah it's like it's the psychosis but you know there's lots of reasons and lots of factors and like there isn't like a one-size-fits-all solution there either so for sure um Mahesh are there for folks who've listened to sort of like want to learn more are there one or two resources websites things that you want me to link to or be sure to link to yeah so I mean like we um so for for folks who are interested in cognitive remediation um uh BCHBankuva Coastal Health we have a page with with some resources to it and if you're in BC and interested in accessing those services you know that's a good link to like where the local groups within the different health authorities as well that that you could look at um my colleague Nicola Wright who wrote the book uh treating psychosis they have a page which has a lot a huge repository of different kind of resources and videos for and that's small for like kind of students and clinicians as well as I think for people who are interested in finding out more about psychosis there and then we have a number of studies again if you're in Vancouver itself so we're doing the study of after therapy that we're just starting off now which we'll be over the next year or so it's a very small trial but I guess and then we're also doing a larger trial looking at whether combining CBT with cognitive remediation enhances outcomes over each individual um um of of the intervention itself so that's kind of a more traditional randomized control trial which is a multi-site study with with colleagues in Toronto Mike Best and and others and then we're doing kind of a hybrid implementation effectiveness trial of like cognitive remediation and MCT medical training uh in routine clinical practice as well so also like studies that are going ongoing and so people are interested in those um they can kind of reach out to to our lab so the lab is called psychosocial interventions for functional improvement or sci-fi and it's sci-fi.lab at UBC dot c a great and I will link to this in the show notes as well so mish this has been wonderful I can't tell you how much I appreciate it hey it's my pleasure man ladies and gentlemen dr. mahesh manan that's a wrap on our conversation about treatments for psychosis as I noted at the top of the show it'd be much appreciated if you spread the word to anyone else who you think might enjoy it until next time
