Psychotropic treatment can often prevent the relapse of psychotic and mood symptoms. However, many patients take medication intermittently or not at all; or the symptoms may be only partially responsive to medication. Therefore, there is a need for interventions that can supplement the effect of medication and improve treatment outcomes.
Cognitive-behavioral therapy (CBT) has been found to be effective for those with severe mental illness.1 Recent meta-analyses have concluded that CBT has a definite effect on positive and negative symptoms in schizophrenia and there is evidence that it can have a sustained effect on attitudes about medication.2,3 The American Psychiatric Association practice guideline on schizophrenia refers to CBT as an evidence-based treatment, especially for persistent symptoms.4 Many other guidelines recommend CBT as well.5 Evidence of the effectiveness of CBT for bipolar and severe depression is more limited, but there are promising results for family work and social rhythm therapy.
Assessment and engagement
CBT involves working with specific symptoms: techniques to help manage delusions, hallucinations, and negative symptoms are based on the development of a good therapeutic relationship between patient and therapist and formulation of the experiences, competencies, thoughts, feelings, and actions of the patient.6
Engaging people who experience psychotic symptoms can be difficult: paranoia diminishes trust, and cognitive impairment and catatonia affect communication. Developing a relationship is a process that requires skill, attention to detail, and adaptation to the patient’s particular concerns.
A good clinical assessment is essential because it provides a wealth of valuable information to inform conceptualization and subsequent intervention and, in itself, can be therapeutic. Details gathered about the first episode of psychosis can be particularly informative. Analysis of the period preceding a psychotic episode can enable the patient to reconsider the conclusions he or she formed at the time, especially if the conclusions evolve into delusional beliefs.
Making sense of the experiences that led to psychosis involves assembling relevant information about predisposing, precipitating, perpetuating, and protective factors with key thoughts, feelings, and behaviors. Connections can be made between precipitating causes and symptoms (eg, stimulant/hallucinogenic drugs and initial psychotic experiences, often viewed as “bad trips”) that further evolved into persistent psychotic symptoms.
Formulation and process Once the precipitating causes are understood, work on delusional beliefs follows. Initially, the process of listening to the patient’s story of how his beliefs developed can improve the therapeutic relationship, allowing discussion and gentle probing about symptoms to begin. It is important for the therapist to begin by “suspending judgment” regarding beliefs. Beliefs may appear to be persecutory (“white vans are following me with intent to destroy me”) or grandiose in nature (“I can influence the weather”). They may include thought broadcast (“the world can hear me thinking”), thought insertion (“you put these ugly thoughts in my head”), or delusions of reference (“the TV show is referring to me”). All beliefs have meaning and function and must be broached with respect and compassion.
It is challenging for any of us to begin considering alternative explanations and ways of being when beliefs are deeply entrenched. A collaborative examination of the evidence offered in support of beliefs can be followed by inquisitive planning of simple experiments. A sample dialogue between the therapist and patient follows.
Therapist: It sounds like you feel very distressed by the belief that your family is monitoring your phone calls. This is an understandable reaction to this belief.
Patient: It’s horrible; I can’t trust anyone. My own family is doing this to me!
Therapist: I’m wondering how much of you believes that your family is doing this, from 0% to 100%?
Patient: I am 95% convinced that they are. All the evidence is there!
Therapist: Okay, so you are pretty convinced. However, there is 5% of you that isn’t convinced. Because of the high cost (distress) of your belief, it may be a good idea for us to check out the evidence for this belief. How does this sound to you?
Patient: The most significant piece of evidence I have is that there is a recording device inside the phone. So perhaps we can plan some simple checks with it? I also saw my mom studying the phone bill last month, but at the time I was too scared to ask her why.
Therapist: So the recording device and your mother studying the phone bill are 2 things we could potentially explore further…?