CBT for Psychosis (CBTp)

With thanks to Joanne Hodgekins for her recommendations

Comments by Margreet de Pater

What is Cognitive behavioural therapy?

A very informative website of the Beck Institute

What Are the Components of CBT? - Delphi Study

How to do CBT? A therapist's manual. - Lara Smith

testimonialspngTestimonials and Stories

CBT for Paranoia - Ian's Story 

Dolly's experience with psychosis and CBT

videoVideo Resources

CBT Treatment Goals for Psychosis

In this video from a recent Beck Institute Workshop, Dr. Aaron Beck describes the shift in treatment aims for clients withpsychosis. He explains that previously "getting better" meant a decrease in symptoms of delusions and hallucinations. Today, Cognitive Behavior Therapy (CBT) aims to help clients function in their communities, whether or not they still experience symptoms. Dr. Beck goes on to say that when clients reintegrate into society, overall adaptive functioning typically improves.

Douglas Turkington, new directions in CBT for psychosis

Dr Turkington has carried out research into the efficacy and effectiveness of cognitive behavioural therapy (CBT) in the treatment of schizophrenia. He has carried out randomised controlled trials of CBT versus befriending and of CBT versus treatment as usual in community settings. He has also conducted short and medium term follow ups. He has written three books on the use of CBT in schizophrenia, one of these being a treatment manual

CBT for Psychosis, An Individualized, Recovery Oriented Approach Instructed by Ron Unge

bookRecommended Books and Articles and Courses

Schizophrenia: Cognitive Theory, Research, and Therapy.
A.T. Beck, N. A. Rector, N Stolar and P. Grant - 2008 Guilford Press

Beck and colleagues leap frog the British contributions and provide a comprehensive volume that is a guide to learning and applying cognitive therapy to schizophrenia.

Cognitive Behaviour Therapy for Psychosis: Theory and Practice
D. Robert Fowler, Philippa A. Garety, Liz Kuipers - 1995 Wiley

Presents a lucid explanation of the clinical guidelines and detailed therapy procedures used in the practice of cognitive psychotherapy for patients with psychotic disorders. Stresses the importance of building a solid therapeutic relationship in the early stages of treatment. Describes a range of cognitive processes to manage diverse types of psychotic experiences and includes procedures aimed at controlling emotional disorders.

A course by Ron Unger

Cognitive Behavioral Therapy (CBT) for psychosis is an evidence-based method to reduce distress and disability related to psychotic experiences, and to support a possible full recovery. Psychotic experiences are conceptualized as being understandable in relationship to an individual's life story, and capable of being altered when people experiment with different ways of thinking and behaving. Learn how to collaborate with people having these experiences, "exploring the evidence" rather than imposing beliefs, and developing coping options so people are not forced to rely entirely on the often limited effectiveness of medication to address problems.

The evidence for CBT

Effectiveness of CBT as a therapy for Psychosis

The following studies evaluate the effectiveness of CBT for Psychosis. There is solid evidence that CBT can be highly beneficial therapy to psychosis. However it must be highlighted that some researchers are disappointed about the results and conclude that CBT must not offered automatically to all people with first psychosis. However there are some surprising outcomes. People with carers seem to profit more from CBT than people without carers. This is also found by Hogerty researching his “personal therapy”. They look at outcomes at 12 and 24 months. With high quality care as usual ‘befriending’ with a treatment team maybe has a protecting effect on preventing relapse. In the Amsterdam study family intervention made a difference not after 24 months (they found few relapses) but it did after 5 years, after the time the relationship with the treatment teams was discontinued. Also see dissertation of Ria Lenior.

Effective elements of cognitive behaviour therapy for psychosis: results of a novel type of subgroup analysis based on principal stratification
Psychological Medicine, 42, 1057-1068.
Dunn, G., Fowler, D., Rollinson, R., Freeman, D., Kuipers, E., Smith, B., Steel, C., Onwumere, J., Garety, P., & Bebbington, P. (2012).

“Consistent delivery of full therapy, including specific cognitive and behavioural techniques, was associated with clinically and statistically significant increases in months in remission, and decreases in psychotic and affective symptoms. Delivery of partial therapy involving engagement and assessment was not effective.”’

Cognitive-behavioural therapy and family intervention for relapse prevention and symptom reduction in psychosis: randomised controlled trial. 
British Journal of Psychiatry, 192, 412-423.

Garety, P, Fowler, DG, Freeman, D, Bebbington, PE, Dunn, G and Kuipers, E (2008)

Citation: “There was a statistically significant reduction in delusional distress at 12 months for those with carers who received CBT; all other results for psychotic and emotional symptoms were non-significant, although a number of other variables indicate a consistent treatment effect that might be common to both CBT and family intervention.”

“This trial found no benefits of psychological interventions, whether CBT or family intervention, for the primary outcomes of relapse and days in hospital. There were limited benefits for CBT on the secondary outcomes of improvements in depression, symptoms and social functioning.”’

Cognitive Behavior Therapy for schizophrenia: effect sizes, clinical models, and methodological rigor. 
Schizophrenia Bulletin, 34, 523-537.
Wykes, T., Steel, C., Everitt, B., & Tarrier, N. (2008).

A large review of 34 RCT’s on CBT showing that people with resistant positive symptoms as a group profit from this therapy

CBT for acute psychosis

Cognitive Therapy and Recovery From Acute Psychosis: A Controlled Trial. 3. Five-Year Follow-Up.

RESULTS: At follow-up no significant differences in relapse rate, positive symptoms or insight between the groups were found, although the CT group did show significantly greater perceived 'Control over illness' than the ATY group. For individuals who had experienced a maximum of one relapse in the follow-up period, self-reported residual delusional beliefs and observer-rated hallucinations and delusions were significantly less in the CT than in the ATY group

CBT for Social Recovery and Negative Symptoms

Negative beliefs can foster negative symptoms in people who suffered from psychosis. In CBT they learn to challenge beliefs like:
It is difficult to be happy unless one is good looking, intelligent, rich, and creative.

  • People will probably think less of me if I make a mistake.
  • If I do not do well all the time, people will not respect me.
  • Taking even a small risk is foolish because the loss is likely to be a disaster.
  • If a person asks for help, it is a sign of weakness.
  • If I do not do as well as other people, it means I am an inferior human being.If I fail at my work, then I am a failure as a person.
  • If you cannot do something well, there is little point in doing it at all.
  • Making mistakes is fine because I can learn from them.
  • If I fail partly, it is as bad as being a complete failure.
  • People should have a reasonable likelihood of success before undertaking anything.
  • If I don't set the highest standards for myself, I am likely to end up a second-rate person.
  • If I am to be a worthwhile person, I must be truly outstanding in one major respect.
  • People who have good ideas are more worthy than those who do not.
  • If I ask a question, it makes me look inferior.

The following articles and book chapters report about the results of this approach

CBT to address and prevent social disability in early and emerging psychosis.
Fowler D., French, P., Hodgekins, J., Lower, R., Turner, R., Burton, S., & Wilson, J. (2013).

Informed by the latest clinical research, this is the first book to assemble a range of evidence–based protocols for treating the varied presentations associated with schizophrenia through Cognitive Behavioural Therapy Deals with a wide range of discrete presentations associated with schizophrenia, such as command hallucinations, violent behaviour or co–morbid post–traumatic stress disorder Covers work by the world′s leading clinical researchers in this field Includes illustrative case material in each chapter

Psychiatric Services, 61, 321-324.
Hodgekins, J. & Fowler, D. (2009).

The findings support those of previous studies that highlight an important role for hope and positive self-concept in the recovery process. Moreover, the study reported here provides a bridge between consumer-oriented and evidence-based practice approaches to investigating and defining recovery. Consumer-oriented approaches highlight the importance of "renewing hope" and addressing the "interpersonal effects" of psychosis.

Randomized Trial to Evaluate the Efficacy of Cognitive Therapy for Low-Functioning Patients With Schizophrenia. 
Archives of General Psychiatry, 69, 121-127.
Grant PM, Huh GA, Perivoliotis D, Stolar NM, Beck AT.

Cognitive therapy can be successful in promoting clinically meaningful improvements in functional outcome, motivation, and positive symptoms in low-functioning patients with significant cognitive impairment

Defeatist beliefs as a mediator of cognitive impairment, negative symptoms, and functioning in schizophrenia. 
Schizophrenia Bulletin, 2009, 35, 798-806.
Grant PM, Beck AT. (2009).

Conclusion: Our findings are consistent with the hypothesis that defeatist beliefs are a mediating variable between cognitive impairment, negative symptomatology, and poor functioning in schizophrenia. Patients showed more defeatist belief endorsement than healthy controls; furthermore, the inclusion of defeatist beliefs in the statistical modeling resulted in an attenuation of the association between cognitive impairment and both negative symptom levels and functioning in the patient sample.

Cognitive Behavioural Prevention of Suicide in Psychosis  a manual by Nicholas Tarrier.

Tarrier, one of the founders of CBT for psychosis, spent the last years of his carrier to investigate suicidal thoughts and behavior of people prone to psychosis and more important, how to help them.  He wrote a very informative book on this issue, with many relevant literature studies and practical guidelines. Text from Amazon (buy the E-book): This practical and informative text lays out the product of a number of years of clinical research into suicide behaviour and its prevention. While the focus is on non-affective psychosis and the schizophrenia-spectrum disorders, the mechanisms underlying suicide behaviour in this group may well underlie or at least influence suicide behaviour in other disorders. The authors describe methods of assessment through individual formulation, and a cognitive behavioural intervention through case studies, to reduce the risk of suicide.

This book argues that:

· Suicide behaviour lies on a cognitive-behavioural continuum from ideation, through intention to action.

· Mechanisms based on biased information processing systems, the development of suicide schema, and appraisal styles are likely to be fruitful in explaining suicidal thoughts and behaviours.

· A psychological theory of suicide behaviour is needed in order to develop a mechanism of suicide and to understand the components of suicidal thoughts and behaviours.

· Suicide risk can be reduced through the use of the intervention methods described within the text

Cognitive Behavioural Prevention of Suicide in Psychosis evaluates practical applications of contemporary research on this topic, and will therefore be of interest to practitioners, post-graduates in training, and researchers studying suicide and/or psychosis.

The evidence

Cognitive-Behavioral. Interventions to Reduce Suicide Behavior. A Systematic Review and Meta-Analysis. Nicholas Tarrier. Katherine Taylor. see Pdf

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