Cognitive Behaviour Therapy

for Psychosis In Practice

David Kingdon
University of Southampton
Southampton, UK
(dgk@soton.ac.uk)
 Therapeutic process of CBT
 There is a strong focus on individualised
engagement of the patient building on good
ENGAGEMENT psychiatric practice
 Agendas are less explicit, feelings are elicited
with great care and homework is used
sparingly
 Assessment is based on clinical practice
ASSESSMENT
 Emphasis is placed on understanding the
first episode in detail, which may hold the
key to current beliefs

 Information on current beliefs and how

FORMULATION they were arrived at is assembled into a
formulation
A formulation for making sense of
patients’ beliefs and experiences

What What started What’s kept it What can

happened it? going? help stop it?
before?

Current problems

Thoughts
Social Physical

Feelings Behaviour

Underlying concerns
Overall aim of CBT for schizophrenia

Work with Work with

delusions hallucinations
AIM
To
reduce
distress
and disability

Work with
negative symptoms
Work with delusions
 Delusions
 trace beginnings of delusion
 build a picture of preceding period
– identify significant life events & circumstances
– identify relevant perceptions (e.g. tingling, fuzzy feeling) &
thoughts (e.g. suicidal, violent)

 explore content of delusion:

– evidence for & then against the delusion
 Delusions
 elicit alternatives:
– ‘can you think of any other possibilities?’
– ‘if someone said that to you, how would you
respond?’
 exploration/investigation of beliefs
– follow up any theoretical proposition,
e.g. that they are being influenced by satellites – suggest
gathering relevant information about satellites

 ‘reality testing’ is useful in assessment &

engagement & may also begin to sew
doubts
 Resistant delusions

 if going round in circles

– ‘Agree to differ’
– review key issues & concerns that have emerged:
e.g. ‘I don’t want to end up like my mother’, ‘I
haven’t got a girlfriend’, ‘I’m useless’
– it may be possible now to work directly with these
– behaviour often changes first …..

 Other psychological techniques may be

helpful, e.g. work on worry & moving on
Work with voices
 VOICES

 Are they distressing?

– If not, is there sufficient reason for
therapeutic intervention?
e.g. effect on behaviour - where it leads to social
ostracization or interference with functioning

 Clarify experience:
– Are they like ‘someone speaking to you like
I’m doing now’..or ‘maybe whispering or
shouting’
 REATTRIBUTION OF VOICES
 Explore the individual focus of the experience
– ‘Can anybody else hear what is said?’ ‘Not parents,
friends, etc?’
 Discover the patients beliefs about the voices’
origin:
– ‘Why do you think others can’t hear them?’
 Debate these beliefs:
– Use techniques for delusions, if appropriate,
e.g. because the CIA have a machine that can do this or
God can speak to people in this way
– Explore doubts: ‘I’m not sure how they come..’
 REATTRIBUTION OF VOICES

 Look for explanations:

– ‘It may be schizophrenia’ (‘but I wish the
neighbours would stop it..’)
– Use ‘normalizing’ alternatives:
deprivation states & other stressful circumstances: eg
bereavement, taken hostage, PTSD;
dreaming/nightmares

 Aim for acceptance of the possibility

that the voices might be to do with
themselves - their own thoughts
 CONTENT OF VOICES

 Explore what they say:

– Weigh up evidence to support and refute what
is said: e.g. ‘you’re useless..’
– Explore any relevance to previous traumatic
events or drug-related experiences

 Explore beliefs about them:

– ‘I have to do what they say’
– ‘They know everything’
 Coping strategies
 Behavioral control
– e.g. relaxation, warm bath, go for walk
 Socialisation
– e.g. friends, day centres
 Medical care
– e.g.. control of medication, call care worker
 Symptomatic behaviour
– e.g. get drunk or drugged, punch policeman
 Cognitive control
– e.g.. TV, music, crosswords,
Work with negative
symptoms
 NEGATIVE SYMPTOMS

 optimise medication regimes

 manage positive symptoms
– especially ideas of reference, voices & thought
broadcasting which can be reactivated as social and
other activity increases
 manage any depression, anxiety &
agoraphobia/social phobia
 NEGATIVE SYMPTOMS
 Consider the protective function of the
symptoms, e.g.:
– avoidance of over-stimulation
– protection from relapse of positive symptoms
 Assess how much pressure the patient and
family perceive:
– Reduce pressure where possible
– Review immediate expectations
– Use realistic long-term planning, e.g. ‘take a year off
then reconsider going to college when you feel ready’
– Reduce level of activity if it is causing distress
 OVERALL AIM

To reduce To promote
– Distress – Empowerment
& &
– Disability – Recovery

CBT work with symptoms, e.g. delusions, hallucinations

& negative symptoms, can be a means to those ends
American Psychiatric
Association Press, 2008
CUP, 2009