Cognitive Behavioral Therapy for Psychosis (CBTp)

As a specialized form of CBT, CBTp is typically used as an adjunctive therapy to antipsychotic medication, as it helps people deal with problems not addressed by medication, including stigma and distress. CBTp is often prescribed after a first incident of psychosis to prevent future episodes. CBTp is appropriate for adolescents and adults who display symptoms of psychosis, such as delusions and hallucinations, as well as for those who are at high risk of developing psychosis.

CBTp is used to help people understand their symptoms so that they can develop ways to cope with them and the situations that trigger them. Early in the course of therapy, individuals work closely with the therapist to develop a "problem" list, identifying the key issues with which they are struggling. The problem list is used to formulate the goals of therapy and to design a path to recovery.

CBTp is a structured form of psychotherapy that is typically conducted in 16 to 26 sessions, each lasting roughly an hour. The exact length of therapy depends on the individual's needs, severity of symptoms, and the treatment plan they develop in collaboration with the therapist. Sessions are usually held weekly or biweekly, spanning anywhere from four months to a year.

CBTp usually begins with several sessions devoted to the establishment of a rapport between the therapist and the individual, before progressing through several distinct phases. The first, engagement phase of therapy aims to build the client’s trust in the therapist so that there is motivation to continue treatment. During this phase, the therapist assists the individual to develop a problem list, which itemizes the issues that are causing them the most difficulties. The problem list establishes the roadmap for treatment. During all phases of treatment, there is an ongoing effort to normalize the individual's experiences—for example, through information demonstrating that psychotic experiences like hearing voices are shared by many people who are not ill.

In subsequent sessions, the client explores their psychotic experiences with the therapist, and they jointly explore the nature of the symptoms in detail—how and when they started, what triggers them, what the client makes of them, and how they react to them. The goal of this assessment phase of therapy is to help the client understand the activating events, the beliefs they hold about their experiences, and the consequences.

CBTp then moves into a formulating phase, in which the client develops an explanation of their psychological difficulties, how their symptoms come about, the problems they lead to, and how their cycle of difficulties is maintained. The goal of this phase is for a client to understand how their problems are connected and to identify points of intervention and develop strategies for doing so.

In the next phase of therapy, individuals apply strategies of intervention and build skills to resolve the problems identified in the earliest phase of therapy (and perhaps modified throughout treatment). For example, clients learn coping skills for managing voices, and they learn classic cognitive techniques to test the evidence for unusual and distressing beliefs.

CBTp usually concludes with several sessions of reinforcing what was learned. Along the way, between sessions, clients get to test their new skills in the real world. The feedback they deliver to the therapist will indicate how well the interventions are working and whether adjustments are needed. Ideally, clients wrap up therapy with the ability to become their own CBT therapist.

Those who complete a course of therapy can expect a reduction of delusions and hallucinations and disordered thoughts, as well as improvement in the negative symptoms, such as reduced emotional expression, decreased motivation, and difficulties in speech and social interaction. In addition, there is evidence that CBTp can prevent or delay the transition to full psychosis when used with individuals identified as being at risk of developing psychosis.

The overarching goal of CBTp is to create understanding of the symptoms of psychosis and reduce the distress they cause, rather than eliminating symptoms. Working closely with the CBTp clinician, following an empirically validated treatment protocol, clients become aware of their thoughts and understand that the way they perceive a situation determines their reaction.

As with all forms of CBT, CBTp is rooted in the present, so the therapist will initially ask clients to identify life situations, thoughts, and feelings that cause distress. Clients are actively involved in their own treatment plan so that they understand that the way to improve their lives is to adjust their thinking and their approach to everyday situations.

While positive symptoms are the most initially apparent and frightening manifestations of psychosis, it is negative symptoms—the loss of motivation, the flat affect, and social isolation—that are ultimately the most debilitating. In his work as head of the psychosocial schizophrenia research unit at the University of Pennsylvania, Beck came to recognize that “the cognitive deficits are important, but more important is the reaction of the individual to all the psychological and social problems, the stigmatization, the bullying,” and their negative beliefs about themselves. “Rather than trying to find some magic bullet to fix the cognitive problems, we get patients to deal with their negative beliefs.”

Working collaboratively with the therapist to make sense of their psychotic experiences is essential to the effectiveness of CBTp. So is normalization of the psychotic experience.

There is no particular certification or license required to practice CBTp, but clients are advised to look for a credentialed mental health professional with specialized training and experience in cognitive behavioral therapy for psychosis. In addition to confirming these credentials, it is important to find a therapist with whom one feels comfortable, as CBT is a collaborative process and a strong therapeutic alliance is critical to its success.