How Does CBT Help People With Psychosis?

Schizophrenia is a chronic disorder marked by bouts of psychosis, or losing touch with reality. It is usually treated with medication that prevents or minimizes those psychotic episodes.

However, in recent years a specialized form of cognitive behavior therapy (CBT) has been shown to substantially help manage symptoms of psychosis. Early treatment with a combination of CBT, medication and family and vocational support has been shown to cut the risk of future psychotic episodes in half. This combined treatment enables people with schizophrenia to take lower doses of medication, with fewer side effects — or, in some cases, to be medication-free.

CBT adapted for psychosis (CBTp) helps a person experiencing delusions (ideas that are not true) and hallucinations (hearing or seeing things that no one else hears or sees) change the way he thinks about and responds to these experiences. The goal is to make them less distressing and less impairing in day-to-day life.

CBT works by helping you examine how you think about a situation, how you act based on your thoughts, and how your thinking and behavior together affect how you feel. If your thoughts and actions are making you feel bad — or making it difficult for you to function — the goal of therapy is to change them and thus alieviate distress and dysfunction.

In the case of CBTp, the therapist’s goal is not to get the patient to question the reality of delusions or hallucinations, but to reduce the damage they can do. “We’re never trying to convince somebody that their experience is not real,” explains Kate Hardy, PsyD, a psychologist who specializes in CBTp at Stanford University’s INSPIRE Clinic, which treats people with, or at risk for, psychotic disorders.

“This is especially important with hallucinations,” she adds, “because they are real. There’s no denying that the person is experiencing a voice that is telling them to do something or saying something about them. But what may be contested is their interpretation of that voice — how helpful is that interpretation?”

The operative word here is “helpful,” not “real.” Dr. Hardy gives an example of a patient who hears voices. Thinking “That’s the devil talking to me and he can hurt me” is likely to make the patient anxious. So the therapist and the patient look for interpretations that might be more helpful.

Some people, she continues, might find it more helpful to say, “Okay, this is my schizophrenia talking.” But given the stigma associated with schizophrenia, some might find that label distressing, too. For them, she adds, it might be more helpful to think, “This is my mind playing tricks on me and I’m really stressed right now.”

Ultimately, the goal is more about reduction of distress than it is about removal of symptoms. “When the distress comes down, the person’s functioning can improve,” Dr. Hardy explains. “So it could be the person is still experiencing auditory hallucinations with the same intensity and frequency, but they’ve learned to interpret that differently. If you don’t believe it’s the devil who’s trying to kill you, you can now go out and do different things.”

Sometimes CBTp enables a patient to see that his own behavior might be causing him problems. Dr. Hardy uses the example of a paranoid patient who is uncomfortable riding the bus because he feels that people are staring at him in a hostile way. The therapist might help explore other possible interpretations of those stares. Could people be stressed or tired or distracted?

And what about the patient’s own behavior? “If you think that you’re not safe,” she explains, “you start to hold yourself and carry yourself differently. Being really hypervigilant and looking around the bus a lot and being angry could actually itself be a reason for people to look at you more frequently” and with more alarm.

The patient might experiment with changing his bus behavior, trying to be “super-relaxed,” Dr. Hardy says, to see what effect that might have on other people’s behavior, and whether that in turn reduces his discomfort about riding the bus.

The first step in CBTp is for the therapist to get a very detailed picture of the patient’s experience.

Dr. Hardy stresses the importance of taking the patient’s perspective seriously — delusions and halucinations included. “Therapists are trained to have a very genuine curiosity about these experiences, and to go on a journey of exploration with the client, rather than just dismissing them as symptoms of psychosis.”

There are standardized measurements for psychotic symptoms, but the experience tends to be so idiosyncratic that the therapist works with the patient to come up with his own way of describing and keeping track of them. For instance, if a patient is hearing voices, the goal would be to specifically understand their negative impact. “What is it about the voices that’s really distressing? Is it how loud they are? Or how frequent they are? Or how mean they are?”

It’s important to recognize that patients may have mixed feelings about their hallucinations or delusions, which can complicate treatment. Someone might say, notes Dr. Hardy, “I really hate that negative voice, but I really like the positive voice, because it’s funny and it makes me laugh.”

Together the therapist and the patient develop a list of the patient’s problems and develop shared goals. Usually, Dr. Hardy says, goals aren’t about reducing symptoms but about getting their lives back. “People often want to focus on having friends or getting back to school, rather than getting rid of, say, voices.”

The next step is to focus on what changes might contribute to helping reach these goals. The therapist’s role might be to suggest, “Does that mean we need to do something about the voices to make it easier to go back to school?”

Most programs for early psychosis treatment allow patients to decide whether or not to take medication. Anti-psychotic medication is the most effective way to reduce or eliminate symptoms, but it has negative side effects, and some decide not to take it or to take it only intermittently.

For patients who aren’t on medication, CBT helps them evaluate how they’re doing and identify warning signs of another psychotic break so preventive changes can be made.

“If a patient is doing well without medication, fine, it stays off the table,” Dr. Hardy explains. But if she’s struggling, the therapist might say, “You’ve been working really, really hard, and yet you’re feeling worse. What do you think about meds?”

Because early treatment can make such a big difference in the trajectory of schizophrenia, there is a movement to identify teenagers and young adults at risk before they’ve had a first episode. And CBTp plays a role in the treatment of at-risk people, too. When warning signs are visible, CBTp has been shown to delay or help prevent the transition into psychosis.

Anti-psychotic medication is also sometimes recommended, but it hasn’t been proven to be helpful, Dr. Hardy says. And “the side-effect profile is such that it’s really not recommended for adolescents who don’t have a fully formed psychotic disorder.”

The difficulty with the at-risk population, she adds, is that the screening and assessment doesn’t accurately predict who will go on to develop psychosis — there are a high number of false positives. That’s why it is a boon to have a low-risk but effective alternative therapy like CBTp.

To find an early treatment center that offers the combination therapy that has proven to reduce the risk of later psychotic episodes, check out the list of programs around the country compiled by Strong 365, a group that aims to fight stigma surrounding psychosis and encourage more young people to get early treatment.