CBT for Psychosis: Effectiveness and Clinical Applications

Introduction to CBT for Psychosis

The Cognitive Behavior Therapy (CBT) approach to delusions and hallucinations enables therapists and clients to investigate and address beliefs and voices, as well as the complexities of delusional beliefs and the manner in which they correlate to the client's personal identity and life. Such inquiry and investigation are normally conducted with neutrality, as the therapist and client together work to uncover delusional networks — belief systems that link behavior and emotions — allowing both parties a window into the way the client experiences the world. Hypotheses are then formulated to help make sense of what triggers the distress or suffering.

Treatment moves on to target and eliminate the triggers of negative beliefs and other negative elements of the client's usual thought processes that interfere with his or her quality of life. The therapist helps the patient connect stressors with vulnerability and to identify negative behaviors and patterns that maintain dysfunctional components in their lives. This can be accomplished through safety-behavior identification, training in coping skills, behavioral experiments, and cognitive therapy — all aimed at stopping or preventing beliefs that needlessly undermine the well-being of the client (Walker, 2013).

Effectiveness of CBT in Treating Psychotic Symptoms

In contrast to CBT principles applied in other areas of psychology, there are several differences when it is used in the treatment of psychosis. Where clients are willing and flexible, they can contribute to an area of therapy that is highly rewarding. Many patients helped to manage their psychosis have reflected that CBT was the first time they felt genuinely listened to, instilled with hope, taken seriously, and treated with dignity. There are significant clinical successes in dealing with mental disorders using CBT approaches grounded in solid theoretical models.

In treating anxiety disorders, the main approach is to test fear-based beliefs through behavioral experiments in order to greatly reduce the symptoms profile or the effect of those symptoms. In treating depression, the focus is the reevaluation of negative beliefs and other excessively limiting thought patterns. In psychosis, the underlying psychological processes are similar to those of depression and anxiety disorders in the experience of hallucinations and delusions. For instance, delusions linked to persecution are conceptualized as threat beliefs connected to the client's efforts to make sense of personal experiences; hallucinations, on the other hand, become problematic when the client conceptualizes them as representing powerful destructive forces. Thus, in CBT for psychosis, fearful thoughts must be reevaluated, withdrawal from social interactions gradually reversed, and feelings of control, hope, and self-worth progressively restored. Clients are given time to express their experiences, and treatment approaches are formulated through collaborative discussion between client and therapist (Freeman, 2013).

CBT Compared to Other Psychological Therapies

CBT has already been tested in treating the symptom profile of schizophrenia and has been found to be effective not only in eliminating some symptoms but also in terms of cost (National Institute for Clinical Excellence, 2002). Other psychological therapies, such as supportive therapy, also alleviate symptoms in approximately 20 sessions. However, cognitive therapy is the only approach known to treat schizophrenia with proven durability (Gould, Mueser, Bolton, & et al., 2001). It has also been revealed, following controlled trials, that the benefits of cognitive behavior therapy translate into community settings (Turkington, Kingdon, & Turner, 2002).

In the controlled trial referenced above, CBT was also found to enhance insight and reduce both depression and overall symptoms. Studies further indicate that cognitive behavior therapy is very acceptable to patients, as dropout rates across different studies averaged between only 12 and 15%. The research also demonstrated the safety of CBT, since no evidence indicated increases in violence, agitation, or suicidal ideation. In spite of these findings, it is acknowledged that when addressing particular types of psychotic symptoms — such as grandiose or systematized delusions, or trauma-related presentations — distressing effects can emerge in the course of treatment. Long-term progress in treating psychotic symptoms using CBT will depend on the further development of psychological frameworks or models of psychotic symptom profiles (in terms of onset and maintenance), as well as the refinement of treatment manuals.

In some cases, treatment using cognitive behavior therapy is thought to be more effective when combined with cognitively sparing antipsychotic medication (Pinto, La Pia, & Menella, 1999) or with cognitive remediation.

Conclusion

CBT has been proven effective in the treatment of depression and has for over five decades been increasingly advocated as a treatment approach for psychosis. There has recently been considerable enthusiasm among clients, psychologists, psychiatrists, and psychiatric nurses for the use of CBT in treating schizophrenia. However, this enthusiasm is often tempered by questions over the actual effectiveness of CBT treatment. Although the use of cognitive behavior therapy in treating psychosis is popular and remains one of the most widely available treatment options for the disorder, shortcuts must not be taken when evaluating the evidence. In a period of limited research funding, every hour or dollar spent on a new technique must be justified (Turkington & McKenna, 2003).

References

Bentall, R. P. (2004). Madness explained: Psychosis and human nature. London: Penguin.

Freeman, D. (2013, December 11). Cognitive-behavioral therapy for psychotic disorders. Psychiatric Times. Retrieved from

Gould, R. A., Mueser, K., Bolton, E., & et al. (2001). Cognitive therapy for psychosis in schizophrenia: An effect size analysis. Schizophrenia Research, 335–342.

Moritz, S., Vitzthum, F., Randjbar, S., Veckenstedt, R., & Woodward, T. S. (2010). Detecting and defusing cognitive traps: Metacognitive intervention in schizophrenia. Current Opinion in Psychiatry, 561–569.

National Institute for Clinical Excellence. (2002). Clinical Guideline 1: Schizophrenia. Core interventions in the treatment and management of schizophrenia in primary and secondary care. London: NICE.

Pinto, A., La Pia, S., & Menella, R. (1999). Cognitive behavioural therapy and clozapine for patients with schizophrenia. Psychiatric Services, 901–904.

Turkington, D., & McKenna, P. J. (2003). Is cognitive-behavioural therapy a worthwhile treatment for psychosis? The British Journal of Psychiatry, 477–479.

Turkington, D., Kingdon, D., & Turner, T. (2002). Effectiveness of a brief cognitive-behavioural intervention in the treatment of schizophrenia. British Journal of Psychiatry, 523–527.

Walker, P. (2013). Cognitive behavioural therapy for psychosis: Lessons from history and hopes for the future. InPsych.

Waller, H., Freeman, D., Jolley, S., Dunn, G., & Garety, P. (2011). Targeting reasoning biases in delusions: A pilot study of the Maudsley Review Training Programme for individuals with persistent, high conviction delusions. Journal of Behavior Therapy and Experimental Psychiatry, 414–421.