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Harnessing the Power of CBT to Treat Psychosis

May 21, 2019

SAN FRANCISCO—Cognitive behavioral therapy (CBT), commonly recommended as part of a treatment plan for mood disorders, can also be an effective intervention for psychotic disorders, a presenter at the American Psychiatric Association’s annual meeting argued.

KingdonDavid Kingdon, MD, of the University of Southampton in England, said CBT can help patients re-evaluate their psychotic thoughts and improve the therapeutic relationship.

“I’ve found that particularly when people are really stressed, anxious, deluded, hearing voices, that what they want to do is want to talk about their voices, talk about those beliefs, talk about getting out of hospital, talk about why they don’t want their medication,” he said.

“That drive is something that can be harnessed very effectively, to engage people in discussing their beliefs, working with their beliefs.”

In conducting CBT, the clinician should not aim to challenge the patient’s thoughts, he said. Instead, the aim should be to understand the patient’s goals and discuss how they can be achieved.

Long ago, medical textbooks advised against using CBT in psychosis, but the field has since moved in the other direction, Dr. Kingdon said. Research supporting it has been developing over the past 20 years or so, he said, however admitting that “there is still a great fear” about using it in some places.

CBT has been demonstrated to be effective for psychosis in China and within a variety of ethnic groups, but there are still questions about using it in people with comorbid severe substance use disorders, according to the presentation.

Dr. Kingdon, a professor of mental health care delivery, estimates that in England, about 70% of patients with psychosis receive CBT. Personally, he has used the technique in psychiatric intensive care units, with inpatients experiencing acute episodes, and in community psychiatry settings.

Among patients with psychotic disorders, CBT is most commonly used in those with persistent psychosis, and administered on a one-to-one basis over at least 16 planned sessions.

“Very few patients don’t take it up if they’re offered it in the right way,” Dr. Kingdon said.

The process includes a strong focus on individualized engagement with the patient, and less explicit agendas on the part of the clinician, he explained.

“If we’re going to engage with that individual, we need to do it on the terms that they’re presenting,” he said. For example, if a patient expresses concern about hearing voices, the clinician should not react by asking about medication adherence.

Dr. Kingdon outlined many techniques which can be used to treat patients experience delusions:

• Try to trace the delusions to the beginning . Family members may be able to help with this.

• Build a picture of the period preceding the emergence of the delusions. Identify significant live events and circumstances and relevant perceptions and thoughts.

• Explore the content of the delusion. Discuss the evidence for and then against the delusion.

• Elicit alternatives. Ask “Can you think of any other possibilities?”

• Use reality testing to assess and engage, and possibly begin to sow doubts in the patient’s mind.

For more information on using CBT to treat psychosis, see the Training to Enhance Communication with Patients with Psychosis (TEMPO) program.

—Terri Airov


“Using cognitive therapy for psychosis in clinical practice.” Presented at: the American Psychiatric Association Annual Meeting; May 20, 2019; San Francisco, CA.

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