There are notable clinical successes in treating common emotional disorders using cognitive-behavioral approaches based on precise theoretical models. In anxiety disorders, the underlying fear beliefs are tested in behavioral experiments to substantially reduce symptoms; in depression, mood is lifted by reevaluating negative views of the self and limiting excessive rumination.
With psychosis, similar psychological processes are active in the experience of delusions and hallucinations. For example, persecutory delusions are conceptualized as threat beliefs that are the patient’s attempts to make sense of his or her personal experiences, while hallucinations are problematic when they are interpreted by the patient as representing powerful and destructive forces. Hence, in cognitive therapy for psychosis, fearful thoughts are carefully reevaluated; withdrawal from social contact and activity is gradually reversed; and feelings of hope, control, and self-worth are fostered. Patients with psychosis are given time to talk about their experiences and, importantly, strategies are developed from this collaborative discussion.
In this one-on-one therapy, distressing experiences take center stage. The first generation of cognitive-behavioral therapy (CBT) for psychosis, when added to standard care, has demonstrated efficacy in treating patients with delusions and hallucinations.1 Although the first-generation CBTs are a significant step forward in treatment approaches, efficacy is moderate. Newer developments in CBT for psychosis are aligning interventions more closely with the transformation in the theoretical understanding of individual psychotic experiences.2 This may well be analogous to the CBT for anxiety: initial approaches showed moderate effect sizes, which were greatly increased by the development of disorder-specific and theoretically driven cognitive therapies.3 Ongoing innovation in CBT for psychosis has garnered the interest of clinicians and researchers across the globe who are becoming increasingly involved.
The initial stages of intervention
A nonjudgmental “voyage of discovery” attitude helps a clinician engage the patient. It needs to be conveyed to a patient that his problems are being taken seriously. The CBT therapist should listen empathically and regularly provide brief summaries to make sure that he has correctly understood what the patient is saying so that he can move the discussion forward.
The distress caused by the experiences is commented on (eg, “it must make you very anxious” or “believing that the neighbors are trying to harm you must feel very intrusive and be upsetting to you”). Patients are engaged in therapy for the explicit aims of reducing distress, increasing confidence, and reengaging in activity. The clinician plays a collaborative role: drawing up a list of goals with the patient, discussing what will happen during the sessions, and regularly asking the patient for both positive and negative feedback.
Anticipating problems with engagement because of mistrust or auditory hallucinations can typically prevent misunderstandings. Immediate concerns (eg, suicidal thoughts, difficulties in getting to therapy sessions) should be dealt with before a full assessment. Challenging delusions in the early stages of therapy is not productive; the more difficult task of listening and trying to understand the patient’s perspective will prove more beneficial. It can also be extremely helpful to occasionally focus on positive aspects and achievements of the patient. Patients with psychosis often present with low self-esteem, difficulties with trust, and fears about others viewing them as “mad”; the clinician who shows positive regard can help circumvent these negative self-views that can hinder engagement.
The initial aim is to develop an individualized understanding that accounts for distressing delusions and/or hallucinations. The ideas used in therapy are based on empirically tested cognitive models of psychosis.4-7 The identification of factors underlying problems is developed using detailed in-session recollections by the patient of recent difficulties (eg, the last time he heard a voice or had a paranoid thought); structured diaries kept by the patient outside of sessions; and assessment of his life experiences, including stresses and current activity. The clinician keeps in mind the psychological ideas and models and will think about the following:
• What is the patient’s emotional state: is he showing a worry style or sleeping poorly?
• What evidence makes the patient believe that the delusional thoughts are accurate?
• Is the patient having puzzling and confusing experiences?
• How does the delusional belief build on the patient’s ideas about the self and others?
• What are his beliefs about the hallucinations?
• How do the delusional thoughts or interpretations of hallucinatory experience make sense given the patient’s previous life events?
• Are there negative images?
• What is the reasoning style concerning these experiences?
• Are there behaviors (eg, avoidance) that contribute to the persistence of the thoughts?
• What is the patient doing during the week?
Dr Freeman is Professor of Clinical Psychology, department of psychiatry, University of Oxford and Oxford Health NHS Foundation Trust, Oxford, United Kingdom, and is a Fellow of University College Oxford. Twitter: @ProfDFreeman. He reports no conflicts of interest concerning the subject matter of this article.
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