Cognitive Therapy of Psychosis


Many people find it very helpful to talk with somebody about the way they are feeling when they are depressed, anxious or confused. One way that has been shown to help with depression and anxiety is to talk about the thoughts that go along with the feelings. So when somebody’s feeling low, it may be because they are thinking of their mother who has died or something else that has happened to them.

When somebody is confused and worried about things happening in their life, it may also be useful to try to work out what thoughts are relevant. So somebody may be upset because they are convinced that they are being followed or persecuted. It can then be worth trying to work out why they think that might be happening.

Cognitive therapy is a way of trying to identify and then understand these thoughts. They may be thoughts that on the surface seem reasonable but the fears have got out of proportion or things have been taken too personally. By weighing up the ‘pros and cons’ of a situation, it can be possible to look at it differently. It may be that there is an alternative to the conclusion that is causing such distress. Anxiety can cause all sorts of strange feelings like numbness or tingling, pain or breathing problems; these can sometimes be misinterpreted as, for example, electric shocks or physical interference by someone and these concerns may helpfully be discussed.

Sometimes there are beliefs which go back a long way which seem to shape how people view situations. For example, if they grew up to believe they were useless, when something goes wrong they may blame themselves, even if it wasn’t their fault. Sometimes thoughts can sound like voices speaking out loud and, when this is happening, cognitive therapy can help people understand and cope with them better.

What is cognitive therapy?

Basically cognitive therapy involves talking to a nurse, doctor, psychologist or other trained person about the concerns and worries and trying to understand them better. This may mean:

  • talking about how problems may have begun
  • discussing how what was happening was interpreted
  • understanding things that happen that seem strange
  • finding out about the sorts of worries the person has

They may be hearing voices when nobody is about, or hear people referring to them as they walk past, or on the TV or radio. There are a variety of other things that can be helped by discussion, e.g. feelings that somebody ior some organisation is persecuting the person or knows what they are thinking. On the other hand they may have beliefs about themselves that others don’t seem to understand or accept, for example, that they are a particularly special person in some way.

For some people, it may help to

  • keep a diary of these thoughts
  • identify particular problems
  • find out more about the beliefs, and how they might be affecting them
  • see if anything particularly makes them better or worse

Coping with troublesome beliefs can be difficult when others don’t believe the person. Talking about them with a mental health worker may help them do so.

Can it help with ‘voices’?

Sometimes people with psychosis can hear someone, or a number of people, speaking or shouting, but nobody else seems to hear them. ‘Voices’ like these can be very distressing: they may say abusive things about the person or tell them to do unpleasant things. Cognitive therapy can help them understand these voices – that they are usually the person’s own thoughts or memories sounding as if they are aloud – and then work out what causes them and what to do about them. Understanding them is important in reducing the fear and anxiety caused and there are also a variety of coping techniques which can help.

Does it work?

There is now good evidence from studies in the UK – Birmingham, London, Manchester, East Anglia & Newcastle – and Belgium that cognitive therapy helps reduce symptoms and time in hospital. It is used in addition to the usual treatments and can help people understand why, for example, medication is useful so that they are more prepared to take it – and discuss their needs with their doctor or keyworker.

What about negative symptoms?

When motivation seems very low and the person seems negative about everything, we describe this as having ‘negative symptoms’. There may be a number of reasons for this, sometimes depression, sometimes voices and delusions which are not immediately apparent. Sometimes there is a fear of these symptoms coming back again and so all stress and stimulation is avoided. After an acute episode of illness, a period of convalescence and healing may be needed.

Expectations need to be very realistic and sometimes this means a radical re-think; it may be an achievement to just answer a telephone call or watch a TV programme even in someone who was previously very capable. Small but readily achievable goals may be set to build confidence. The therapists may even advise that initially enduring a waiting period of just calm stability is appropriate, though not always easy to do.

Doesn’t talking about voices and delusions make them worse?

There is a common belief amongst doctors and nurses that talking about voices and delusions makes them worse by focusing attention on them. Some psychiatric text books have advised against such discussion but there seems no direct evidence to support this. It is clearly wrong to force someone to talk about something if it distresses them but allowing them to talk, as occurs in cognitive therapy, seems humane and can be positive. If the person does become distressed, the conversation can be interrupted and then continue later, if appropriate. Where the discussion becomes repetitive, it probably is sensible to ‘agree to differ’ – a skilled cognitive therapist will then use techniques to overcome such blocks.

Can you use cognitive therapy instead of medication?

All the studies which have shown cognitive therapy to be effective have used it in combination with medication – including using some studies in which clozapine and the newer drugs, like respiridone and olanzapine, have been used. Sometimes people will accept drugs but not cognitive therapy, and sometimes therapy but not drugs – but it seems that the combination is best.

How can I get cognitive therapy for myself or my relative?

Because it is so new, there are still only a few trained therapists around the UK and even fewer elsewhere but more are being trained on ‘THORN Psychosocial Interventions’ and other courses.