Cognitive-Behavioral Therapy for Psychotic Disorders

Psychiatric TimesVol 30 No 12
Volume 30
Issue 12

The first generation of cognitive-behavioral therapy for psychosis, when added to standard care, has demonstrated efficacy in treating patients with delusions and hallucinations. Details in this article.

Figure. Example of a formulation diagram for a persecutory delusion

Figure. Example of a formulation diagram for a persecutory delusion

A summary of the main intervention techniques for delusions and hallucinations

Table: A summary of the main intervention techniques for delusions and hallucinations

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?

The answers to these questions are proposed to the patient for his opinion (eg, “I may have this wrong, but could it be that given the things that have happened in the past that your first reaction now is to think that others will be bad to you?” “Might it be that not sleeping is making things feel worse?” “It sounds like you worry a lot and doing this makes your concerns feel even worse?”). Gradually the therapist and patient develop a shared understanding, with the focus on what is maintaining the current problems and what can immediately be changed. The past and initial onset of problems are brought into the discussions when appropriate (and to varying degrees).

The Figure illustrates the onset of paranoid experiences that result from a spiral of stresses (isolation →drug taking →poor sleep) and lead to an odd perceptual state. A paranoid interpretation of the odd state is understandable given the context of long-standing social anxiety, a tendency to worry, and hasty reasoning. The reaction of avoiding situations leads to the failure to receive disconfirmatory evidence, and the paranoid fear becomes entrenched. Sharing this formulation with the patient to describe his subjective experiences may help him understand what is happening. Patient accounts are used to emphasize elements of the formulation.8

It is important to note that cognitive therapies were developed in a tradition that interventions should be assessed for their efficacy and therefore formal measures of symptoms are routinely taken to monitor treatment effectiveness (eg, the Psychotic Symptom Rating Scales).9 If change does not occur, the clinician needs to change course: weekly therapist supervision is advisable and close links with treating teams need to be maintained.


Making sense of psychotic experiences illuminates many potential therapeutic paths. For example, the clinician may work on reducing negative beliefs about the self, limiting the time spent worrying, improving sleep, reducing drug taking, and increasing engagement in positive activities before addressing the delusional belief. There is evidence that simply improving sleep and reducing worry using CBT techniques developed for emotional disorders leads to reductions in psychotic symptoms.10,11 This kind of work moves the intervention into an active phase beyond simply talking and it raises the patient’s confidence in the clinician.

Delusions. A number of strategies can be used for delusions (Table). If anomalous experiences are assessed as central to delusion formation-odd experiences that lead to odd ideas-they are targeted. The nature of the anomalous experiences can be explained to the patient (eg, “Part of the difficulties seem to come from when you feel as if the world is unreal. This is called derealization and is something people often experience when they are feeling miserable. Would you like me to find out if there is any good reading on this experience?” “It seems a large part of the difficulties are these terrible feelings of anxiety you get when you step on to the bus, is that right? Perhaps these terrible feelings are the central problem and you would feel more comfortable around people if those sensations weren’t so strong?”).

A functional analysis is carried out to identify the triggers and reactions to the anomalous feelings. The patient is encouraged to respond differently to the triggers, to reduce the occurrence of the anomalous feelings (eg, if the feelings occur when the patient is irritated by someone’s behavior, assertiveness techniques might be taught). Or the person may be encouraged to cope differently with the anomalous feelings, to prevent a vicious circle of overreaction and anxiety that leads to more unusual experiences. At this point, asking about images that support the delusions may be useful.12 Another strategy is reviewing, reality testing, or modifying delusions. Patients are shown how to verbally review their delusional thoughts and to develop alternative explanations for the delusions (weighing up the evidence for and against).

However, beliefs are often best changed via experience, and behavioral experiments can be used to alter delusional beliefs. Hierarchies of tests are constructed, predictions are made, and the results of tests are considered. This work has to be done very carefully in agreement with the patient. Often it is best to put the alternative belief (eg, the patient will not be attacked, the voices cannot do what they threaten) to the test. In some cases, patients will not wish to consider alternative explanations for their experiences or to doubt the basic premises of their beliefs, or the beliefs are not possible to test. In these instances, it is necessary to work within the delusional system. For example, focusing on the most troubling aspects of the delusional system (eg, showing that the persecutor has less power than the patient thinks) or helping the patient return to positive functioning by improving his coping skills (eg, using flash cards with information for use in social situations).

Hallucinations. A central technique when working with hallucinations is to consider the patient’s interpretations of his voices. Interesting theoretical studies have shown that relationships that patients have developed with their voices often mirror real-world experiences.13 The basic cognitive model is that it is the interpretation of events, not simply the events, that determine emotional reactions. For example, the patient may believe that the voices are out to get him and that the voices can carry out any threat. The belief that the voices have such power is reviewed and tested out, just as for a delusional belief.

Trower and colleagues14 describe how they focus on beliefs that the voices have power and control and that the person must comply and on beliefs concerning the identity of the voices (eg, the devil) as well as the meaning attached to the voice experience (eg, that it is a punishment for previous behavior). The therapist talks with the patient about what is the most helpful attitude and relationship to the voices and how to achieve this while acknowledging that it takes time for changes to occur. Perhaps the patient can be engaged with the voices only for a set period each day, and then he can focus on something he would rather do or accomplish. Sometimes an analogy is made with having a noisy next door neighbor or a bully in order to think how best to react to voices.

Often the triggers for auditory hallucinations are periods of anxiety or inactivity. Therefore, an individual’s triggers for voices are identified and alternative ways of acting or structuring the day are developed (eg, if the voices only occur when the person is lying awake in bed at night, it might be appropriate to increase activity during the day and ensure the person is only going to bed when very sleepy).

It can also be helpful to enhance a person’s coping strategies when hallucinations do occur. Some people find it helpful to wear headphones or to read, hum quietly, or seek company when voices occur. Another helpful strategy is to provide information written by other voice hearers. This can help the patient realize that he is not alone and can show him ways to adapt to the hallucinations. A promising new strategy to target the depression associated with voices is to develop competitive positive memories to use when voices occur.15

Emotional concerns and activity. Throughout therapy there is ongoing work to improve the patient’s self-esteem; reduce depression, anxiety, and worry; increase activities; and structure the week (including paying attention to regular and more healthy meals). Finally, the therapist and patient try to prevent relapse by identifying vulnerabilities and early warning signs and rehearsing compensatory strategies.

Overall, it should be clear that CBT draws on a range of techniques that are applied on the basis of individual formulations of a patient’s difficulties. However, the unifying factor is the assumption that a patient’s experiences should be taken seriously and that the patient can be helped to make psychotic experiences less threatening, less interfering, and more controllable.

Future direction

There is still much to do in the development of CBT for psychosis. The key treatment techniques for each individual psychotic experience (eg, paranoia, grandiosity, hallucinations, anhedonia) need to be identified. Approaches targeted to negative symptoms are only now emerging.16,17 CBT techniques for psychosis differ depending on whether the focus is on preventing episodes, reducing relapse, increasing speed of recovery from an acute episode, or reducing persistent delusions and hallucinations.18,19 Issues regarding comorbid alcohol and drug abuse need to be considered and the therapy adapted to specific demographics.20,21

We are entering an exciting period of finding out how best to address psychotic symptoms. Identifying the moderators and mediators of CBT for psychosis will refine treatment and enhance patient outcomes. Although self-help and internet-delivered interventions are still in their infancy and require further research, we’ve come a long way in our understanding of how to approach and treat patients-we’ve realized that it is preferable to openly discuss psychotic symptoms with the patient.

Acknowledgment-Dr Freeman is supported by a UK Medical Research Council Senior Clinical Fellowship.


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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3. Clark DM. Developing new treatments: on the inter-play between theories, experimental science and clinical innovation. Behav Res Ther. 2004;42:1089-1104.

4. Freeman D, Garety PA, Kuipers E, et al. A cognitive model of persecutory delusions. Br J Clin Psychol. 2002;41(pt 4):331-347.

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8. NHS Foundation Trust: Institute of Psychiatry. Paranoid thoughts. 2012. Accessed October 30, 2013.

9. Haddock G, McCarron J, Tarrier N, Faragher EB. Scales to measure dimensions of hallucinations and delusions: the Psychotic Symptom Rating Scales (PSYRATS). Psychol Med. 1999;29:879-889.

10. Myers E, Startup H, Freeman D. Cognitive behavioural treatment of insomnia in individuals with persistent persecutory delusions: a pilot trial. J Behav Ther Exp Psychiatry. 2011;42:330-336.

11. Foster C, Startup H, Potts L, Freeman D. A randomised controlled trial of a worry intervention for individuals with persistent persecutory delusions.J Behav Ther Exp Psychiatry. 2010;41:45-51.

12. Schulze K, Freeman D, Green C, Kuipers E. Intrusive mental imagery in patients with persecutory delusions. Behav Res Ther. 2013;51:7-14.

13. Birchwood M, Gilbert P, Gilbert J, et al. Interpersonal and role-related schema influence the relationship with the dominant “voice” in schizophrenia: a comparison of three models. Psychol Med. 2004;34:1571-1580.

14. Trower P, Birchwood M, Meaden A, et al. Cognitive therapy for command hallucinations: randomised controlled trial. Br J Psychiatry. 2004;184:312-320.

15. van der Gaag M, van Oosterhout B, Daalman K, et al. Initial evaluation of the effects of competitive memory training (COMET) on depression in schizophrenia-spectrum patients with persistent auditory verbal hallucinations: a randomized controlled trial. Br J Clin Psychol. 2012;51:158-171.

16. Grant PM, Huh GA, Perivoliotis D, et al. Randomized trial to evaluate the efficacy of cognitive therapy for low-functioning patients with schizophrenia. Arch Gen Psychiatry. 2012;69:121-127.

17. Klingberg S, Wölwer W, Engel C, et al. Negative symptoms of schizophrenia as primary target of cognitive behavioral therapy: results of the randomized clinical TONES study. Schizophr Bull. 2011;37(suppl 2):S98-S110.

18. Morrison AP, French P, Stewart SLK, et al. Early detection and intervention evaluation for people at risk of psychosis: multisite randomised controlled trial. BMJ. 2012;344:e2233.

19. Gumley A, O’Grady M, McNay L, et al. Early intervention for relapse in schizophrenia: results of a 12-month randomized controlled trial of cognitive behavioural therapy. Psychol Med. 2003;33:419-431.

20. Barrowclough C, Haddock G, Wykes T, et al. Integrated motivational interviewing and cognitive behavioural therapy for people with psychosis and comorbid substance misuse: randomised controlled trial. BMJ. 2010;341;c6325.

21. Rathod S, Kingdon D, Phiri P, Gobbi M. Developing culturally sensitive cognitive behaviour therapy for psychosis for ethnic minority patients by exploration and incorporation of service users’ and health professionals’ views and opinions. Behav Cogn Psychother. 2010;38:511-533.

Additional Reading

• Freeman D, Freeman J, Garety P. Overcoming Paranoid and Suspicious Thoughts. New York: Basic Books; 2008.

• Hayward M, Strauss C, Kingdon D. Overcoming Distressing Voices. London: Constable & Robinson; 2012.

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