Coping with Psychosis: Using CBT to Manage Persistent Symptoms

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.