Cognitive-behavioral therapy (CBT) is being used as an adjunct to
pharmacotherapy to treat the core symptoms of schizophrenia, but it differs in
important ways from CBT as it is typically used with affective disorders.
A substantial literature, mostly from the United Kingdom, now supports the
efficacy of CBT for psychosis, and the treatment is considered standard for
antipsychotic-resistant schizophrenia there.
But at APA's 2008 Institute on Psychiatric Services last month in Chicago,
U.S. psychiatrists who are successfully using CBT said that treatment of
psychosis requires modifications of traditional CBT—as well as a
departure from some long-accepted tenets about the treatment of severe mental
Page Burkholder, M.D., said that adapting CBT to the treatment of psychosis
requires clinicians and patients to collaboratively seek alternative ways of
understanding and managing the hallucinations and delusions of psychosis.
Burkholder is with the Schizophrenia Research Program at SUNY Downstate
Medical Center in Brooklyn, N.Y.
These fundamentals include "radical collaboration" with the
patient and normalization of psychotic experiences.
"Radical collaboration really means being curious with the person you
are speaking to, coming from where he or she is, and trying to find out what
is distressing to the individual," she said. "This is different
from the medical model because you try to make the differences between
yourself and the patient not so hierarchical.
"Normalizing means looking at the fact that many people have strange
events in their thinking and perceptions, not just people who are labeled
psychotic," Burkholder said. "You don't have to use the word
'schizophrenia' or [the term] 'severe mental illness.' You can use the
stress-vulnerability model because that is a good way to offer an alternative
explanatory rationale. Everyone understands stress; with enough stress, anyone
can have a psychotic experience. Some people don't take very much stress for
that to happen."
Examples of normalizing can include exploring with the patient anomalous
experiences common to many people, such as hearing one's name called in a
crowd; sensing a loved one's presence after his or her death; hallucinations
that can occur with sleep deprivation; as well as certain religious,
spiritual, or philosophic beliefs.
"Everything is a continuum," she said. "There is a
continuum of beliefs and a continuum of options. We don't have to start at the
point where [the patient] is ill and has a biological brain disorder. But we
also don't have to say that the patient isn't having any problems. So we
normalize [those symptoms] and introduce possible alternative
Burkholder said there is a body of literature reporting randomized,
controlled trials of CBT for psychosis. "Most of the research comes out
of the United Kingdom, finding that it is most helpful for people with chronic
refractory psychosis. Whether and how it is useful for first episode is still
being studied. The literature is not definitive, but it is robust."
Michael Garrett, M.D., described the successful use of CBT to treat
psychosis in a woman who was initially adamantly opposed to taking
antipsychotic medication due to having previously experienced severe side
By exploring the personal meaning of the voices she heard, she came on her
own to understand the voices as the externalized sound of her own thoughts. A
psychoanalyst, Garrett also explored with the patient the meaning of the
voices and their relationship to significant persons in her life, as well as
to the grief she felt over recent losses.
He also offered her a neurobiologically informed metaphor for understanding
the working of her mind: a window that because of an excess of dopamine was
opened wide, so that her overflowing grief poured out in the form of
externalized voices. In time, he could suggest that certain medicines could"
close the window," and after eight once-a-week sessions of CBT
without medication, the patient expressed an interest in trying
"The case shows how CBT for psychosis can work hand in hand with
psychopharmacology," Garrett told Psychiatric News. "On
the one hand, symptom improvement with psychopharmacology can help patients
get maximal benefit from CBT. On the other hand, CBT can prepare the way for
He is vice chair and a professor of clinical psychiatry at SUNY Downstate
Yulia Landa, Ph.D., of Cornell University Medical Center in New York City,
described her group-therapy program for paranoid delusions. Patients are first
taught to identify cognitive biases like excessive personalization and jumping
to conclusions that predispose to paranoid beliefs. After learning to identify
these cognitive biases, group members examine each other's beliefs to
determine where cognitive biases might be operating in their personal
Despite the success of the technique, aspects of CBT for the treatment of
psychosis require psychiatrists to depart from some long-held tenets, said
Peter Weiden, M.D., coauthor of a summary of research on CBT for psychosis
that appeared in the March 2006 American Journal of Psychiatry.
"The growth in this field, primarily in England, does not come from
people who specialize in CBT with affective disorders, but from people
interested in psychosis who are frustrated with limited outcomes [associated
with conventional treatment]," Weiden said at the institute.
Those clinicians have adapted CBT in special ways to the treatment of
psychosis, he said. "One of the radical things about this is the belief
that one can change core symptoms of schizophrenia," Weiden said, as
opposed to only influencing affect.
Weiden said the degree to which the clinician is called upon to align with
the patient and the normalization of psychotic symptoms will be difficult for
psychiatrists trained in the medical model. "This is a big break in the
tradition of how we evaluate psychosis," he said. "Typically you
have to either prescribe an antipsychotic or you don't. Either you are
psychotic—that's bad—or you are not. But in the world, psychosis
is on a continuum, and that is the belief you need to have in a CBT
He added that psychiatrists have traditionally been taught that taking an
interest in the personal meaning of symptoms—as in Garrett's case of the
woman's voices—is contraindicated. "Patient-centered treatment is
very in vogue, but with CBT for psychosis, the clinician is aligning with
patient goals and what [patients] want to a degree clinicians would not do
normally," he said.
Along with David Kimhy, Ph.D., an assistant professor of clinical
psychology in the Department of Psychiatry of Columbia University College of
Physicians and Surgeons, Burkholder, Garrett, and Landa have founded the
Institute of Cognitive Therapy for Psychosis in New York City. They are in the
process of developing a Web site, but in the meantime clinicians interested in
learning more about the institute may e-mail Garrett at
TheAJParticle, "Cognitive Behavior
Therapy for Schizophrenia," is posted at<http://ajp.psychiatryonline.org/cgi/content/full/163/3/365>.▪