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Cognitive Behavioural Therapy for Psychosis

Written by Philip Houghton on . Posted in Clinical Psychology Bite-Size

Cognitive Behavioural Therapy for Psychosis

Issue 13 – April 2009

Author: Phil Houghton (philip.houghton@nottshc.nhs.uk)

Key points

  • We need to adopt a more modest and questioning view of CBT for psychosis, as whilst it can be a helpful approach the evidence base is not as strong as is sometimes suggested 

Implications for practice

  • The helpful ingredients of CBT for psychosis include talking to people about their psychotic experiences, trying to understand the meaning of them for the person within their wider context, and working collaboratively on shared goals.
  • Challenging a person’s beliefs directly can often be unhelpful 
Cognitive-Behavioural Therapy (CBT) for psychosis is an approach which in its purest form argues that it is not events themselves (e.g. voices) but a person’s interpretation of those events that leads to distress. The theory then follows that by helping an individual to view those events in a different way we can reduce the distress. Whilst on the face of it this seems plausible, this article will argue that we need to take a fresh look at CBT for psychosis and arrive at a more modest view of what it is and what it can achieve (for a fuller discussion of the points raised in this article see Houghton, 20051).

The limitations of CBT for psychosis

Much of the research base argues that CBT is an effective treatment for psychosis2 and superior to both routine care and supportive therapy3. Reading the headlines one would assume that anyone with psychosis can see a CBT therapist and come out the other side cured of their psychotic experiences. Of course this is not the case and my belief is that the evidence has been over exaggerated to an unhelpful point where both the worker and the service user can be left feeling like a failure when this so called “tried and tested” 4 intervention does not significantly reduce the person’s distress. Indeed, even CBT’s most ardent supporters5 remind us that clinically noticeable change will not bring people back into the ‘normal’ range. Moreover, there are also questions over whether CBT for psychosis is actually more beneficial than someone spending time reflecting on the person’s experiences6. Another limitation of CBT for psychosis is the lack of attention the model pays to a person’s social context. CBT’s focus on attempting to change someone’s perception of events ignores the fact that many people have truly distressing social contexts (e.g. poor housing, poverty, stigma and discrimination) and that challenging someone’s beliefs will not influence these major causes of distress. It is unhelpful to simply focus on someone’s internal world as this locates the problem within the person. We can then see our job as attempting to fix the person’s beliefs and wrongly blame ourselves or the person when change does not occur. Rather, we should try to understand the person’s difficulties and beliefs within their social context and use this understanding to inform what might be helpful. It is my experience that people can at times be helped by feeling that they have more control over their experiences, however, it is actually rare that service users who have enduring idiosyncratic (“delusional”7) beliefs fundamentally shift these beliefs through therapy.

The strengths of CBT for psychosis

Notwithstanding the limitations there remain many positive aspects to take from the approach. As a model it does move away from the biological models of psychosis in emphasising the meaning someone attaches to their experiences, rather than seeing them as meaningless outcomes of biochemical pathology. CBT promotes the idea that an individual’s psychotic experiences are embedded within their developmental history, and that often this history can in part not only cause the person to have unusual experiences, but also influence how they view and cope with those experiences. Perhaps the most important factor that CBT promotes is to talk to service users about their unusual experiences, what they mean to them, how they might link with other aspects of their lives, and what might be helpful. It encourages us as workers to be curious about service users’ experiences, and spend time collaboratively discussing what the person’s current goals are and what might help them gain greater control over their distress. Whilst one does not need to use a CBT framework to do this, on occasions it can be helpful and at this level does not require extensive training within the specific techniques of the model. This does not mean it is easy, but the skills needed of warmth, understanding, patience and curiosity allow such conversations without necessarily having more formal therapy qualifications. For me such conversations underlie the positive research findings for CBT for psychosis rather than the specific ways of approaching peoples thoughts found within CBT models 1. Indeed, it can often be unhelpful to challenge peoples’ thoughts, especially before one has a positive therapeutic relationship with the person, and a good understanding of not only the negative, but the positive impact of how they view their unusual experiences.

Summary

In sum, the evidence base surrounding CBT for psychosis is much more flimsy than is often presented, and simply viewing the person’s distress as a result of their beliefs and then challenging these beliefs is unhelpful and can potentially make things worse. However, there are a number of positives to the approach which whilst certainly not exclusive to CBT do form part of it. These include talking to people in a curious, collaborative way about the meaning of their experiences within a historical context. If we then add in consideration of the person’s social reality we can hopefully develop shared understandings that can inform possible ways of reducing the service user’s distress.

REFERENCES

  1. Houghton, P. (2005). Stop the Juggernaut: How effective is cognitive behavioural therapy for psychosis? The evidence proves rather less than is sometimes claimed. Mental Health Today, February, 22-25.
  2. Gould., R. A., Mueser, K. T., Bolton, E., Mays, V. & Goff, D. (2001). Cognitive therapy for psychosis in schizophrenia: an effect size analysis. Schizophrenia Research; 48, (2-3), 335-342.
  3. Rector, N. A. & Beck, A. T. Cognitive behavioural therapy for schizophrenia: an empirical review. Journal of Nervous & Mental Disease, 189 (5), 278-287.
  4. British Psychological Society. (2000). Recent advances in understanding mental illness and psychotic experiences. London: British Psychological Society, 2000. This document can be downloaded at www.understandingpsychosis.com
  5. Kuipers, E., Garety, P., Fowler, D. et al.(1997). London-East Anglia randomised controlled trial of cognitive-behavioural therapy for psychosis. I: Effects of the treatment phase. British Journal of Psychiatry, 171, 319-327.
  6. Cormac, I., Jones, C., & Campbell, C. (2002). Cognitive behaviour therapy for schizophrenia (Cochrane Review). The Cochrane Library, Issue 3. Oxford: Update Software.
  7. Collinson, C. (2008). Understanding “Delusions”, Clinical Psychology Bite-Size, Issue 5.
 

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