Cognitive Behavioural Therapy (CBT) is a psychological methodology applicable to psychosis treatment, which was developed from a foundation combining the basic tenets of behavioural and cognitive psychology. The philosophy behind the approach in this context is that the problems arise not due to the hallucinations and delusions themselves but to the beliefs and appraisals the individual attaches to these which may subsequently lead to aberrant behavioural responses.

CBT has a different mechanism of action to pharmacological interventions which aim to eliminate symptoms. Instead CBT can be effective in allowing the individual to reappraise the content of associated delusions and hallucinations. This subsequently enables them to minimize the psychopathological impact and change the trajectory of their psychotic condition towards a more manageable scenario approaching normality with a corresponding improvement in life quality. It also proves to reduce cognitive bias, distress caused in particular social settings and actions that are subsequently carried out in response to hallucinations and delusion.

CBT for psychosis should be tailored to the individual as the experiences are idiosyncratic with likely secondary features combining to create a unique psychopathological expression. An open-minded empathetic approach is necessary to allow the individual to talk about their issues comfortably and build a trusting collaboration, with validation rather than dismissal of their psychotic perspective and accompanying delusional ideas. They would also need to establish a genuine desire and motivation to pinpoint issues for positive change (Smith et al. 2003).

Delusions and hallucinations are common features of psychosis. The former being irrational beliefs which do not fit a cultural framework, occupy far too much attention or cause distress. The latter being perceptual illusions which can take form in any of the sensory modalities. Auditory hallucinations, with voices being particularly common can be subdivided into malevolent and benevolent voices. Delusional beliefs fall into the categories of voice identity, potency, meaning, and commanding nature (Chadwick, P. & Birchwood, M. 1994). CBT has proven to reduce the individual’s conviction towards their delusions via recognizing and questioning their beliefs. The primary method used in CBT is clinical consultation during which care must be given collaborate with the patient. Thus, condescending words such as hallucinations and delusions are not favoured, but rather words such as ‘concerns’ and ‘worries’ are used so as not to run the risk of psychological reactance.

The goal of the consultation is to assess the hallucinations and delusions. Hallucinations in the CBT approach are regarded as stimulating sensations but the primary focus is the delusions or beliefs which may or may not accompany the hallucination. As it is the beliefs which inevitably cause the psychological distress (Smith et al. 2003).

Once the hallucinations are identified, they are characterised based upon their physical nature. For example if auditory then whether it is a voice and if so where is projecting it from? The second metric is the content of the hallucination such as what the voice might be saying.

Delusions and beliefs are identified and assessed based on the strength of and preoccupation with it (Chadwick, Lees, & Birchwood, 2000). For example, if it is about a voice then relevant features would be the patient’s belief about who the voice belongs to, the commanding quality of the voice and its power over them.

Following consultation and assessment. The therapist can initiate a variety of methods to reduce the disturbance and distress such as introducing new coping measures, logical and rational approaches for examining the evidence for the delusions and techniques to help reduce emotional turmoil.

Challenging delusional beliefs and reality tests utilized in CBT have been proven to substantially reduce the distress caused by hallucinations and associated delusions. Thus, with CBT the distress and symptom manifestation can be alleviated to some degree by targeting the cognitive and behavioural defects that lead to a vicious cycle which maintains or may even advance the severity of the psychotic disorder.

References:-

Smith, L., Nathan, P., Juniper, U., Kingsep, P., & Lim, L. (2003) Cognitive Behavioural Therapy for. Psychotic Symptoms: A Therapist’s Manual. Perth, Australia: Centre for Clinical Interventions.

Chadwick, P. & Birchwood, M. (1994). The Omnipotence of Voices A Cognitive Approach to Auditory Hallucinations. British Journal of Psychiatry (1994), 164.

Candida M, Campos C, Monteiro B, Rocha NBF, Paes F, Nardi AE, Machado S (2016). Cognitive-behavioral therapy for schizophrenia: an overview on efficacy, recent trends and neurobiological findings. Medical Express. 2016;3(5)