We are at a crossroads in our understanding and approach to psychosis. Biological paradigms and treatments are narrow in their understanding of psychoses and limited in their ability to promote recovery. There is evidence that some psychotic experiences are “normal,” some are traumatogenic, and many are self-limiting and growth-promoting.1
Psychiatrists who treat patients with psychosis in institutional, community, and crisis settings provide evaluations and medication management but rarely consider psychotherapeutic interventions.2 However, such interventions can be critical in recovery. Current guidelines recommend cognitive behavioral therapy (CBT) as evidence-based psychotherapy for schizophrenia.3,4
Principles of therapy for psychosis
CBT for psychosis (CBTp) follows the general principles and approach of therapy for depression and anxiety with some modifications to address positive psychotic symptoms, cognitive deficits, and stigma associated with psychosis. The stages of therapy include building a therapeutic alliance, developing a formulation, specific interventions to build skills to address symptoms and improve functioning, relapse prevention to enhance resilience, and specific interventions to address stigma.
Ideally CBTp consists of at least 10 sessions over a 6-month period with specially trained therapists. Although CBTp is not widely available, a variety of CBTp-based interventions can be used widely. These components, which take 5 to 20 minutes, are clinically effective.5 The mnemonic CUT-PAR (connect, understand, teach, practice, ask, review) denotes the basic framework of these interventions (Table 1). A deeper connection with a psychotic patient is possible when the psychiatrist has a compassionate attitude, mental state of mindfulness, and uses a variety of strategies as detailed in the Table. Understanding the problem includes turning the existing problems into an actionable plan and enhancing motivation to take action. The take-home work is tailored to the patients’ cognitive and motivational capacities and can be as simple as reading given material or rating mood in different situations.
Asking for feedback reduces the power differential and allows the psychiatrist to change his or her intervention or style. The importance of feedback is even more important when a patient is from a different cultural background.6 The patient reviews the session, and the psychiatrist adds to it. The psychiatrist may want to provide index cards or a notebook for the patient to write down what was learned in the session as well as any take-home assignments.
The CBT approach to delusions is based on the principle of collaborative empiricism. The psychiatrist approaches the delusional belief with an open mind and in a spirit of discovering the truth—akin to the method of a true scientist. There are 8 targets for interventions in delusions.
1 The first is addressing distress associated with delusions through empathic exploration. Mary, a 32-year-old woman, believes that men are entering her house at night and talking about rape. The psychiatrist might say, “It must be very scary for you at night when you are hearing this talk about rape.” Such a response helps the individual lower her defensive stance and discuss her distress. The follow-up would be to bring up any existing coping mechanisms with a question such as “Can you tell me what helped you to deal with this situation for the past 3 weeks?” Psychiatrists often find useful information about the unique coping strategies of their patient. In the above scenario, Mary found prayer to be helpful in protecting her.
2 Sometimes a lack of real-world information can contribute to the development of delusions, and an intervention to explain how things work in the real world can sow a patient’s doubt of the delusion or change how a patient responds to a delusional belief. Annie, a 35-year-old woman, stopped taking her antipsychotic medication because she believed that the pharmacy had given her a different-colored pill to poison her. In this instance, the psychiatrist educated Annie about generic medications and about the FDA, which monitors every aspect of medication manufacturing, distribution, and dispensing. Once Annie learned about the oversight of pharmacies, she agreed to go back on the medication as a trial.
Dr. Pinninti is Professor of Psychiatry, School of Osteopathic Medicine of Rowan University, Stratford, NJ; Dr. Gogineni is Professor of Psychiatry, Cooper Medical School of Rowan University. The authors report no conflicts of interest concerning the subject matter of this article.
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