At present, there are no open slots in our psychosis program. In order to better address the needs of the psychosis community, we are redirecting our focus from weekly sessions with individuals experiencing psychosis to prioritizing education for both professionals and non-professionals. By enhancing the training of more professionals, we believe we can extend our support to this community that we are deeply committed to. Nonetheless, we remain available for consultations, which can include individual, family, or professional sessions.

“Psych-” as a root is defined as “mind”, while the suffix “-osis” is defined as a condition, status, or process, whether typical or atypical. So, the word psychosis points to a condition of mind. It is a broad description of less common or more extreme experiences that we all may have had, or could have. It is only an issue to the degree that the associated experiences are the source of impairment, distress, or harm.

More people live with psychosis than most of us realize.

It is common, and it can be manageable.

What is Cognitive Behavioral Therapy for Psychosis?

CBTp is a form of psychotherapy aimed at helping individuals manage and reduce the symptoms of psychosis, which may include delusions, hallucinations, and disorganized thinking. It involves working collaboratively with a therapist to understand and change negative thought patterns and behaviors. It has been a valuable support for many people in learning how to live a more fulfilling life while living with intermittent or regular psychotic experience.

What is the history of CBTp?

CBTp evolved from Cognitive Behavioral Therapy (CBT), a well-established psychological treatment. The adaptation of CBT for psychosis emerged in the late 20th century as research began to show that psychological therapies could effectively complement medication in treating psychotic disorders.

What evidence supports the efficacy of CBTp?

Numerous studies have shown that CBTp can be effective in reducing the severity of psychotic symptoms, improving functioning, and enhancing quality of life. It is recognized as an evidence-based intervention for psychosis in various clinical guidelines worldwide.

What are the phases of therapy in CBTp?

CBTp typically includes the following phases: Assessment and Engagement, Formulation, Intervention, Relapse Prevention and Maintenance, and Termination. Each phase plays a crucial role in the therapeutic process.

Why is the Engagement Phase emphasized in CBTp?

The Engagement Phase is crucial as it involves building a therapeutic alliance and trust, which is essential for effective therapy. In psychosis, individuals may have mistrust or ambivalence towards therapy due to their symptoms. Hence, more time is often spent in this phase to develop a strong, collaborative relationship.

Why is the Engagement Phase typically longer in CBTp?

The extended duration of the Engagement Phase in CBTp is due to the unique challenges presented by psychotic symptoms. These can include distrust, fear, and a lack of insight into the illness. A longer engagement phase allows for the development of trust, understanding, and a strong therapeutic alliance, which are vital for the success of the therapy.

How can families support individuals undergoing CBTp?

Families can play a supportive role by encouraging the individual's participation in therapy, being understanding of their challenges, and providing a stable and supportive home environment. Educating themselves about psychosis and CBTp can also be beneficial.

Is CBTp guaranteed to work?

While CBTp has been a powerful treatment tool for many people, it isn't the right tool (or the right tool for a particular time) for everyone. We can never guarantee an outcome. What we can guarantee that we'll do what we can with the knowledge base and resources we have to best support you or your loved one in taking steps toward the change that you aspire to. If we don’t have the tools or level of care that you need, we can discuss options for other regional supports who may.

Excellent question! Not everyone is a good candidate for our program. After you read this, review the question in our FAQ “What are the requirements for your CBTp program?” The information there is a version of the contract we have our clients and their chosen support person sign after we have mutually decided to initiate therapy. Prior to even scheduling, however, there is something that makes someone ready for this type of program, and that is a readiness to engage. We have found that if a client isn’t choosing, from their own readiness and free will, to be part of our program, it is not the right time for them.

We sometimes use an analogy we call “A Ripe Peach” to describe one of the reasons why this is important. Imagine plucking a peach off of a peach tree. A peach that is ripe drops in the hand with ease. There is limited to no effort. But, if the peach isn’t ready, you might yank, pull, and tug to try to get that peach to come off the branch. In the process, you bruise and damage the peach. Similarly, if someone isn’t ready to engage by their own volition and internal motivations, a resistance or distaste for this kind of support can build. In this way, we may damage the potential they may have had in the future to re-engage at a later time when they may have felt more ready and received benefit.

Another question that is important to consider is the degree to which someone is experiencing impairment or distress. If an individual is a voice hearer, but the voices are not causing impairment or distress, there may not be a need for therapy, unless the individual seeks it out for other reasons. The level of impairment or distress is key.

Cognitive Behavioral Therapy for serious mental illness has better outcomes when it includes three things: 1) therapy 2) support from someone who cares for the person experiencing psychosis , and 3) enough stability to make use of the process (often, for those in early stages, this involves medication).

Due to our limited resources as a small private practice without the access to the full range of support or menu of services available in a larger agency, our ability to build a team to help our clients achieve their life goals is crucial. Therefore, we ask our clients to have a family member or another loved one involved in their care.

The following are conditions for initiating and continued therapy with our office:

1. Family/Support Person Meeting: The client and their chosen support person agrees to having care meetings, as needed. The frequency and duration of these meetings varies from person to person and as their needs fluctuate. During times of stability and maintenance, meetings may be as brief as 15 minutes and be scheduled intermittently throughout the year, or not at all. During other phases of therapy, monthly or more frequent meetings may be important. The intention of these meetings is for everyone on the team to “check in” and stay updated with the progress and plan, or coordinate around crises. Collaboration can help us all as we work together with a shared vision toward a client’s desired therapy goals. This is in addition to weekly private sessions with the client and billed at a rate commensurate with the client’s hourly rate, reflecting the time spent and billed per 15 minute segments. (ie; the fee for a 15 minute meeting would be 1⁄4 of the fee of the client’s regular therapy rate). Often, but not always, these meetings can be tagged onto the final 15-30+ minutes of a client’s session, so no further balance accrues beyond the anticipated therapy session.

2. Signed Release to Discuss Care: The client agrees to sign a Release of Information allowing us to freely communicate and discuss care with the family/support person, as needed, to more easily coordinate care during a crisis, to minimize crisis risk, or best support the client in meeting their therapy goals. These discussions always have client support at their core and are mostly educational in nature, often in support of deepening the understanding of information learned in the REACH Program (see below for more on REACH). For some clients, these conversations with a support person occur only during crisis.

3. Crisis plan: Many of our clients find themselves in crisis from time to time. This is a natural part of a more serious or complicated mental health condition, especially in earlier stages, and it's important to prepare prior to a crisis unfolding. Therefore, the client & family/support person agree to both fill out a Crisis Plan before the first family meeting, or as otherwise agreed upon with your therapist. After completion, all parties agree to a family meeting to review and finalize the plan, and to make agreements as to follow through with the plan if a crisis should arise. This is a first draft that will be refined over time. We recognize that some may need this plan more than others, however we can't anticipate who will benefit vs not. Therefore, having a written crisis plan on file is standard policy for all clients in our CBTp program.

4. Prescriber: The client agrees to have a psychiatrist or APRN in place at the initiation of therapy (or within a timeframe mutually agreed upon with our office) to prescribe & manage appropriate prescription medications, and to have an active Release of Information on file allowing SLR to discuss your care with them.

5. Attendance: We have some special attendance policies for our CBTp clients. We request that all clients make contact with us if they are going to miss a session. Client agrees to miss no more than 5 sessions without prior notice and a legitimate reason for the cancellation in a 12 month period. All parties agree that if more than 5 sessions occur as described above, or the client has 2 missed sessions in a row without prior notice and a legitimate reason for the cancellation, therapy will be put on hold. If this “hold” status occurs, in order to assess how to move forward, all parties agree to meet to assess continued interest in therapy, assess the therapy plan moving forward, renegotiate agreements for therapy, and make sure all parties continue to be “on board” with involvement. If a client does not make contact with us for 3 consecutive weeks, they are formally discharged from our program. Exceptions may be made for special circumstances. We request that a support person keep us informed in times of crisis and hospitalization.

6. Family SPIRIT Lab Resources & Completion of REACH Program: The family/support person agrees to familiarize themselves with the resources available through the SPIRIT Lab at the University of Washington. The family agrees to complete the online “on-demand” portion of the REACH Program within 4 weeks of involvement of care, and either the online or in-person half day live portion of the training within 6 months. At the time of writing, the live portion is offered 4 times a year. If the next immediate session is full, one can add their name to a contact/wait list for the following session. This program is offered for free or low cost to families.

Here are some helpful links to get you started. Use these links as a jumping off point to explore the other related webpages from the SPIRIT Lab:

• SPIRIT Lab at the University of Washington | Supporting Psychosis Innovation through Research, Implementation, & Training (uwspiritlab.org)

• Psychosis REACH Training | SPIRIT Lab at the University of Washington (https://www.psychosisreach.org/)

We’re dedicated to supporting you or you (or your loved one) through your mental health journey. As we begin our work together, it's important to recognize the limitations of a small independent practice and online telecare services, such as ours, in crisis situations. Our goal is to ensure that you receive the appropriate care and support, especially when facing urgent challenges. As a standard practice for all of our clients with more complex mental health needs, we encourage and require the development of a personalized crisis plan.

Understanding Our Limitations

Our Services: As a small private practice with a single practicing therapist, we specialize in providing weekly therapy sessions, hosting intermittent family meetings as needed, and conducting educational groups on topics relevant to our clients and their loved ones. Additionally, we sometimes act as a referral resource, guiding clients and their families to other available supports as their needs evolve. Recognizing the limitations & staffing shortages often found in larger agencies, our clinician(s) also sometimes offer external therapy sessions adjacent to the services an individual might receive from these agencies.

Note: If you have Medicaid, please bring it to our attention so we can discuss with you the higher level of services that may be more readily available to you and offer a greater level of care.

Our Expertise: Our clinician is highly skilled in managing complex mental health issues and is widely sought out by clients, families, and fellow professionals for his expertise with psychosis. However, it's crucial to understand that our practice is not a large agency equipped with a diverse array of services. We do not provide access to a multidisciplinary team or comprehensive "wrap-around" services. Our capabilities do not include offering peer support, prescribing medications, or providing 24-hour crisis intervention and vacation coverage. Additionally, we do not have caregivers who travel to clients' homes or other natural settings.

Our Role in the Community: We acknowledge that our pared down services, without the multidisciplinary resources & programs of larger agencies, offers an imperfect solution to a significant gap in Washington State's mental health care system. This gap predominantly affects individuals with complex mental health needs who are not yet eligible for Medicaid and thus lack access to larger agencies with more extensive resources. By offering our specialized services, we aim to partially bridge this gap and provide much-needed support to this underserved population.

Crisis Situations: As a practice with only a solo clinician, we may not be as equipped as a larger agency to handle acute crises, such as severe psychotic episodes, grave disability, or situations where there is a high risk of harm to oneself or others.

Session Flexibility: We do offer flexibility for additional therapy sessions, collaboration, and collateral care coordination during times of crisis, but this may not suffice in every crisis scenario.

Creating a Crisis Plan

Early Preparation: It is crucial to have a plan in place before a mental health crisis emerges. Therefore, we encourage and require the development of a personalized crisis plan, in writing, early in our therapeutic relationship. This plan will outline steps and resources to utilize during emergencies.

Regular Reviews: Your crisis plan should be reviewed and updated regularly to ensure it remains relevant and effective. For instance, as you learn and establish new practices, tools, or resources that improve your ability to engage with your experience, we can add them to your plan.

Involvement of Family/Loved One: We require a family member or another support person to be involved in crisis planning, to agree to be an active part of the crisis plan, and to follow through with their role in the plan should a mental health crisis arise. This requires participation in crisis planning both outside of and during family meetings.

Plan Accessibility: Keeping your plan quickly easily accessible for both yourself and your support person can help in times of crisis. Your support person can quickly locate the plan should symptoms escalate so they know who to call and remind themselves what your wishes are. It's also important to consider how your medical team might access your plan if medical care or hospitalization takes place without immediate notification of your support person. Planning ahead to increase your care team's access to your crisis plan during times when symptoms may interfere with the ability for introspection and action can help the care team access the information that reflects your wishes for treatment. There are a variety of ways people manage this, including having their plan on file at your local/regional emergency and crisis services, or wearing a medical alert bracelet or necklace which has information directing the care team to a service that can connect them with their crisis plan. Some choose to keep a flash drive around their neck or in their purse, clearly marked for emergencies.

Emergency Resources

Immediate Assistance: In case of an emergency, please contact local emergency services, call 911, or a crisis hotline. We request that clients find & be prepared to share the contact information of their local & regional crisis resources to include in writing on their crisis plan.

Other crisis contacts include:

Crisis Line: 988 or text HOME to the number 741741
Veterans Crisis Line: 988 (press 1) or text 838255
24 Hour Crisis Line / Peer Support: 1-866-427-4747 (https://www.crisisconnections.org/wa-warm-line)/

List of Resources: We encourage clients and their loved one/support person to locate regional crisis supports, such as respite programs and inpatient psychiatric care facilities, before they are needed. Keeping contact information for these resources easily accessible on a written crisis plan can minimize stress should an urgent need arise. We ask our clients and their loved ones to gather, at minimum, contact information for crisis emergency services in their preparation for their crisis planning meeting. Please ask us if you have difficulty finding services in your region and we will attempt to support you in that process.

Additional Information

Clarifying Terms: Terms like "grave disability" and "acute psychotic episodes" refer to situations where an individual is unable to care for themselves or poses a direct threat to their own or others' safety.

Confidentiality in Crises: Our commitment to your confidentiality remains paramount, even in crisis situations.

However, please be aware that there are some cases in which we are legally permitted, & in some cases required, to share information about our clients on a limited basis. Examples of some scenarios that fall under these legal disclosures include cases when there is a threat of harm to self or others, life-threatening scenarios, incapacitation, or other emergencies. Even in these cases, we disclose only that which is necessary and to the extent consistent with professional judgment & standards of ethical conduct.

Feedback and Support

Your Voice Matters: We welcome your feedback on this policy. If you have questions, need clarification, or have ideas on how we can better support and care for our clients, please feel free to reach out to us. We understand that facing a crisis can be overwhelming. Please know that we are here to support you in creating a safe and effective plan for such situations. Your well-being is our priority.

A mental health crisis is any situation in which a person’s actions, feelings, and behaviors could lead to them hurting themselves or others, and/or put them at risk of being unable to care for themselves or function in the community in a healthy manner. 

Creating a crisis plan during a time of relative calm can help someone continue to experience a greater sense of autonomy should a mental health emergency arise. It's a collaborative plan, largely based on your input, that assists your team in supporting you in your most challenging moments. Some people also like to revisit their plan to help manage symptoms more regularly, even outside of times of crisis. By using this information to create a plan, you & your team can more effectively work to prevent or manage a mental health crisis as it develops, increasing the potential for support measures to be implemented with early signs of difficulty to mitigate potential harm.

There are 3 steps to crisis planning: 
1) Planning - during times of calm
2) Utilizing the crisis plan - during times of need
3) Modifying the plan - based on new insights that arise throughout therapy and within post-crisis reflection 

As we progress, it is natural for self-awareness and understanding of behavioral patterns to grow with each experience. This plan is dynamic and meant to evolve, allowing for edits as we gain insights into how your mental health condition affects you and what proves most supportive for you. 

In our practice, we can use a joint crisis plan to guide and further explore your answers. When complete, both you and your support person should keep a copy of the crisis plan, which will be created from the information, and any other important care documents in a location that is quickly and easily accessible during times of crisis.

Yes. Our approach is an integrated one, where we consider both mental health and substance use issues concurrently. We call it Integrated Recvovery Principles (IRP) for Co-occurring disorders. This approach is unlike many other service providers who typically provide sequential or parallel approaches to treatment. In the former, an individual receives treatment for substance use at a different time, and often with a different agency, than they do their care for their mental health. In the latter, an individual receives treatment from two separate agencies at the same time for these two issues.

In our experience and training, we see that these issues have a strong influence on each other. They aren’t independent of each other. For instance, if someone hears voices they find distressing, they may have developed a habit of using substances as a coping mechanism to alleviate that distress. How can substance use be effectively addressed if the voices are still causing distress? And, how effective will it be if the agency treating substance use has no training in working with more complex mental health experiences? What if the approach taken by the agency treating substance use is at odds with the approach taken by the agency treating mental health?

Our approach blends the care for substance use and mental health as one integrated approach.

There are many was you or a loved one can learn about psychosis and substance use, which is commonly used as a coping tool.

As we find resources we think may be valuable for clients and their loved ones, we add them to our resource pages, found under the “Learn” tab.

We regularly work with loved ones & others who wish to learn more about how to better support someone experiencing psychosis in a general way, or helping learn to navigate their own emotional response and wellness if a loved one is experiencing a serious mental health condition. This support can be a one-time consult or ongoing weekly support, if your loved one is not our client. 

For loved ones who are formal clients of ours, support meetings are part of our program to the degree that they best support our client. The intention of these meetings is for everyone on the team to “check in” and stay updated with the progress and plan, or coordinate around crises. Collaboration can help us all, as we work together with a shared vision toward a client’s desired therapy goals. These meetings most often occur with our client present, however on some occasions such as during times of crisis (or impending crisis), conversations with a support person may occur independently of our client and are held with the same guiding questions: “How can we best support the person who has put their trust in us as our client?”, “How can we best help them meet their goals?”, and “How do we implement the crisis plan they have created?”

Another resource for loved ones is The SPIRIT (Supporting Psychosis Innovation through Research, Implementation, & Training) Center at the University of Washington: https://uwspiritcenter.org.

Psychosis REACH is a training offered through the SPIRIT Center that offers concrete, evidence-based skills for relatives and friends of individuals with psychotic disorders to better care for and relate to their loved ones. Information on the training can be found at https://uwspiritcenter.org/psychosis-reach-overview/. This training is free or low cost, has historically been offered four times a year, and can fill up quickly. If you are interested, you may want to sign up as soon as a session is announced in a timeframe that works for you.

There is a range of experience that comes with psychosis, from pleasant to neutral to distressing. For many people (probably more than you may imagine!), it has limited to no impact on their daily function, levels of happiness, or life stability. In other cases, episodes of psychosis can completely reorganize a person’s life and the lives of those around them. There may be losses and uncertainty of many kinds, from roles & responsibilities in employment & education, to large changes or letting go of plans & dreams. There can be a lot of new information and new kinds of experience to navigate. This is true for both the actual internal experience, as well as navigating new systems of healthcare and insurance. We want to offer some reassurance to those of you reading this who are in this more destabilizing stage. By and large, things do get easier over time for most people. 25-30% of people achieve remission after one episode, while 60-80% experience recovery or significant improvement in longitudinal studies worldwide. A majority have no problems related to voices or delusions at a 20 year follow up. For those with ongoing psychotic experience, there is a learning process that happens with each episode. Whether that is learning about the internal experience itself, what triggers it and how to engage it, or learning about the systems that one uses as external supports, these things can feel easier to manage over time. With each episode comes a valuable opportunity to turn into one’s own personal detective to closely examine how it works, and how to work with it. These skills accumulate, leading to more of a sense of capacity to navigate them when they do.

We have some video resources linked under our “Learning” tab on our website. Some of these videos are of people who have had fairly challenging experiences, just like many of the clients who see us, and who have gone on to learn how to better navigate and find a sense of greater stability and wellness in their lives. The guidance and support of someone who can help you explore and guide the way can be invaluable in this process.

While users often report that the use of cannabis (marijuana) alleviates a variety of health conditions, it may not be the best fit for you if you’re at risk for or experiencing psychosis. We understand that many people turn to marijuana and other substances to cope with the experiences they’re having. Despite its reputation for low harm and high benefit, cannabis can pose risks in those who experience psychosis. The potential mechanisms for cannabis-induced psychosis are not fully understood. It has been shown to damage white matter, which may lead to psychotic symptoms in people at risk. In multiple studies, early cannabis use, before age 15, has been associated with a high increase in risk of developing schizophrenia, compared to non-use individuals.

Interactions with AI chatbots can potentially worsen psychosis, especially in individuals who are already vulnerable or have pre-existing mental health issues. These chatbots may reinforce delusional beliefs and negative thoughts, leading to increased psychological distress.

Recent studies and anecdotal reports indicate that a small percentage of users show signs of mental health emergencies after using AI chatbots. Some cases have linked chatbot interactions to suicidal ideation and severe psychological distress.

While AI chatbots can offer companionship and support, they also pose significant risks for individuals with mental health vulnerabilities, potentially worsening psychotic symptoms.