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 illness.

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 explanations."

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 effects.

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 aripiprazole.

"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 effective psychopharmacology."

He is vice chair and a professor of clinical psychiatry at SUNY Downstate Medical Center.

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 beliefs.

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 session."

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 Michael.Garrett@downstate.edu.

TheAJParticle, "Cognitive Behavior Therapy for Schizophrenia," is posted at<http://ajp.psychiatryonline.org/cgi/content/full/163/3/365>.▪