Coping with Psychosis: Using CBT to Manage Persistent Symptoms

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Jennifer Gottlieb, Ph.D., NARSAD YI, Dartmouth Medical School
Jennifer Gottlieb, Ph.D.

From The Quarterly, Fall 2011

Upwards of half of people taking antipsychotic medications continue to have some symptoms of psychosis. Cognitive behavioral therapy (CBT) is a non-pharmaceutical intervention that helps people develop skills for coping with persistent delusions and hallucinations as well as some of the social problems attendant on schizophrenia. A highly structured, usually short- term treatment, CBT is based on collaborative interaction between patient and therapist. A key aspect of this therapy is that patients play an active role in their treatment with the therapist as a kind of coach.

The first step is for the patient to examine the coping strategies he or she has been using and how effective they are. A list of other possible strategies is provided and patient and therapist brainstorm about some ways that might work. For example, if the patient is hearing voices, the therapist helps to instill the idea that it is the patient’s own thought, and that the voice is a bully. The patient is asked to think about when the voices come and what reactions they evoke. Studies have shown that people who hear voices are not just upset about what the voices say or the experience of hearing them, but the belief that if they don't listen and do what the voices say, they will be punished.    

Unfortunately, access to CBT treatment is extremely limited. An informal survey Dr. Gottlieb conducted a while ago turned up only six of 50 states where CBT is being used for psychosis. Obstacle include the lack of clinicians trained in the therapy, a continuing shortage of funds for programs and ongoing misconceptions as to whether or not it is possible to do  psychotherapy with people with schizophrenia.

Dr. Gottlieb is currently developing programs for computerized cognitive behavioral therapy for psychosis. One is intended to help people cope with voices. Another already in place is helping people cope with paranoia. These are interactive, game-based programs that teach CBT skills, providing interaction, the ability to do homework and report back and to try out different kinds of strategies. A two-year pilot study will evaluate the program’s effectiveness.

Article comments

This internet-based cognitive behavioral therapy sounds promising. How can my family member participate in this program? Please advise.

Thank you,
Grace Travinsky

Yes I would be interested in Internet CBT program too !

I have schizophrenia. Here is some fuel for thought and research...

You say the voices are the persons own thoughts. Why is it "often" not consistent with the persons thinking at the time, often not the persons beliefs, so negative when humans usual think positively, the opposite of the persons reality, and their are many more arguments about how you may explain it to a patient correctly or understand it as a mental health personnel.

Schizophrenia is very complex and can not be understood or explained in a basic way.

I would like to know how soon will this therapy be available for use to my family member?
Thank you

I would be very interested in knowing when and how this program could be available.

I am interested in this program. It might just help to improve my family member's insight. Please let me know when it will be available.

I would urgently welcome a program to help a family member use cbt

I just read a fascinating book that might be of interest to people dealing with the "voices" issue. It's called Energetic Boundaries, by Cyndi Dale.

I am looking for a self help program to use at our office for peer to peer mentoring program
any thoughts?

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Please note that researchers cannot give specific recommendations or advice about treatment; diagnosis and treatment are complex and highly individualized processes that require comprehensive face-to- face assessment. Please visit our "Ask an Expert" section to see a list of Q & A with NARSAD Grantees.
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