Cognitive behaviour therapy (CBT) is a form of talking therapy. It focuses on thoughts and feelings and behaviours and how these affect each other. It is based on the idea that ways of thinking and behaviour can help cause mental health problems, or help to keep them going. CBT therapists aim to help people to improve their mental health through making changes in their thinking and behaviour. In psychosis, the aim is to reduce the distress caused by hallucinatory voices, and improve coping.
CBT involves a collaborative approach between patient and therapist. Both patient and therapist have an active part role.
At the beginning of CBT the patient and the therapist agree what problems to work on, and some specific goals.
Patient and therapist then work together to develop a ‘case formulation’. This is a set of hypotheses which attempts to explain how the patient’s problems have come about and what keeps them going. The formulation is then used to identify changes in thinking or behaviour that may be helpful.
A wide variety of techniques are used to change thinking and behaviour. Often these begin with self-monitoring, for example keeping a diary of thoughts and feelings. Different forms of CBT differ in how much emphasis is put on thoughts and how much on behaviour. Techniques may involve identifying and challenging negative thoughts, unhelpful beliefs and assumptions or experimenting with different behaviours and monitoring their effects. Some of the work of CBT is done between sessions, as ‘homework’.
CBT sessions are structured. They usually begin with agreeing an agenda of what is to be discussed in the session and a review of any homework. They generally end with a review of the session and maybe agreeing homework for the following week.
In CBT for psychosis, the emphasis early on is on trying to create a good therapeutic relationship, so that the patient feels able and willing to engage in the work to be done. Therapists provide information about psychosis, and in particular try to make clear how psychotic experiences lie on a continuum with non-psychotic experience. This is called ‘normalizing’. The latter stages of therapy will usually focus on relapse prevention. It is considered very important that the patient is offered hope and belief in the possibility of recovery.
CBT therapists have traditionally been active researchers, and there has been much more research into CBT than other forms of therapy. The research suggests that compared with standard care, CBT may reduce readmissions to hospital, reduce symptom severity, improve depression, social functioning and negative symptoms (1).
For more information, see the ISPS book CBT for Psychosis (2)
NICE. (2009). Schizophrenia:Core interventions in the treatment and management of schizophrenia. National Institute for Health and Clinical Excellence.
Hagen R, Turkington D, Berge T, Gråwe RW (2011) CBT for psychosis: A symptom-based approach. Hove: Routledge.