Cognitive therapy for psychosis

Cognitive therapy has established itself as an effective intervention for psychosis and is now a requirement in the NICE schizophrenia guidelines. The evidence is strongest for positive resistant to medication alone. There is also now support for its use with negative symptoms, early intervention and comorbid substance misuse. Therapy involves a focus on successful engagement, assessment and formulation as the basis for the use of specific techniques for delusions, hallucinations and negative symptoms. Tracing the antecedents of psychotic breakdown, building a picture of the prodromal period, and understanding beliefs about the events and perceptions allow re-evaluation of these beliefs. These can then be debated constructively and alternative explanations explored. This enhances engagement and, where conviction is less than absolute, may lead to their modification. Where conviction is high, techniques can be used to access key underlying issues and sow sufficient doubt for patients’ behaviour and subsequently beliefs to change. Work with hallucinations involves understanding external attributions and then discussing them and normalizing the experiences. Coping strategies would be developed or reinforced and the content of voices, often very negative, questioned. Negative symptoms were conceptualized as often protective, sometimes a consequence of depression, anxiety or positive symptoms, and frequently accompanied by demoralization and even feelings of being under pressure. Techniques to manage such issues have proved successful in research and clinical practice.