A Curious Lens: Cognitive Behavioral Therapy for Recovery and Resiliency
Abstract: This article explains how clinicians employing Cognitive Behavioral Therapy for psychosis collaborate with clients to decrease the distress caused by symptoms of psychosis.
"A Curious Lens: Cognitive Behavioral Therapy for Recovery and Resiliency" (2016)
By Sara Deal & Valerie Alt
The Experience: Imagine you are boarding a bus. You step onto the bus and pay your fare. You look up to the faces of other passengers; many of them glance over as you find your seat, and a few people stare. Someone catches your eye and you're convinced he is part of a governmental conspiracy that you have been suspicious of for some time. These paranoid thoughts dart in and out of your head, making you increasingly uncomfortable, scared, and confused about how you became a target. You quickly scan the rest of the seats and notice more and more people staring at you. Beads of sweat start to collect on your forehead. You hear a voice saying "We will get you, we will get you." You're not sure where it is coming from, but assume it must be one of the riders behind you. At the next stop, you exit the bus, constantly looking over your shoulder to make sure no one is following you.
Sounds scary? Imagine navigating a world where everyone tries to convince you that there is no conspiracy, asks "Have you slept enough?" or offers their opinion that "You sound crazy."
Living with psychosis symptoms can be confusing. Individuals often receive terrifying and contradictory messages from their sensory world coupled with invalidating feedback from others' responses to their stories and beliefs. It's easy to feel isolated and misunderstood when you are told that what you experience isn't "real," and is "an illness."
Cognitive Behavioral Therapy for Psychosis (CBTp) is an opportunity to see these experiences in a new light. CBTp is a collaborative approach which aims to increase our awareness of how our thoughts, feelings, and behaviors are linked when we respond to and interpret internal and external events. Through this approach individuals gain perspective into how they view their experiences and life events. CBT is a well-established treatment for anxiety and depression.1 It is now broadly recommended as a first line treatment for psychosis by the National Institute for Health and Care Excellence in the United Kingdom2 and the Schizophrenia Patient Outcomes Research Team (PORT) report in the US.3
CBT for psychosis differs slightly from CBT for anxiety and depression in that the initial focus is not to reduce symptoms, but rather to reduce the distress caused by the symptoms. Symptoms are not conceptualized as challenges to be eliminated, but are explored as warning signs that something else may be off for the person experiencing them. For example, a client may stop spending time with friends due to the voices she hears throughout the day and as a result she feels lonely and sad. A CBTp clinician might work with this client on coping skills (behavioral intervention) to manage and distract herself from the auditory hallucinations. This would allow her to spend time with friends again and feel less sad and lonely.
The clinician may also work with the client around her understanding of the voices (cognitive intervention) to increase insight and identify more helpful and accurate thoughts. This client may still hear the voices, but her functioning is less impaired due to the coping skills and an improved way of making sense of the voices. At the heart of this journey of exploration is normalization. Psychotic symptoms are part of the continuum of human experience – any person is capable of these symptoms given the right circumstances (e.g., stress, drugs, trauma). Understanding this can normalize the clients' experiences and empower them to feel less alone. Clients are able to begin shifting their interpretation of their symptoms and associated thoughts, emotions, and behavioral responses, in order to move toward productive and affirming goals.
The real-life scenario above was drawn from the experiences of a young man who was experiencing frightening and unusual beliefs on a daily basis. He began missing school and was isolated from his friends. Each week, we worked through these distorted thoughts and interpretations to help him better distinguish his symptoms of psychosis from reality. Slowly but surely, he was able to identify his triggers and use adaptive coping skills to manage his stress. He began to see the relationship between specific triggers, stress, and his symptoms. He learned skills such as finding evidence for and against his interpretation, keeping a coping card of his alternative beliefs about people on the bus, deep breathing, and wearing headphones to distract from potentially distressing voices. Over time, he was able to reduce the impact and severity of his symptoms.
These cognitive and behavioral changes were possible because of a relationship with the clinician built on collaboration, mutual respect, trust, and communicating that these experiences are not abnormal. CBTp gives clients a safe space to talk about confusing and scary experiences while working together with a clinician to identify solutions. Curiosity and openness are at the core of CBTp, with the ultimate goal being to understand the client's experience and together choose an appropriate intervention.4 The clinician also uses questioning in order to increase the client's insight into how earlier life experiences have contributed to the way she makes sense of the world today. This roadmap serves as a way for both the clinician and the client to navigate current patterns of thinking, feeling, and behaving.
Through exploration, psychoeducation, and emphasizing that unusual and distressing beliefs are within the normal continuum of human experience, clients are able to reframe and understand experiences within a different, more normalized context. CBTp clinicians strive to understand and empathize with their clients' reality, whether it is entangled in systems of delusions or based on hallucinations, and identify how to decrease the distress. Morrison states that many symptoms of psychosis can be thought of as intrusions into the awareness – and that it is the interpretation of this intrusion that causes distress and impaired functioning.5 As clients work towards learning how to manage their distress, the next step can be to explore how the meaning attributed to symptoms is an underlying source of the maintenance of certain patterns of thinking and behavior. The clients and clinicians work as a team, with the clients in the driver's seat, to untangle distress and barriers, increase clients' understanding of what is happening, and learn how they may respond. The goal of this work is to support clients to return to functioning as they once were, and hopefully to continue thriving in life.
CBTp encourages us to be open and at the same time think critically. Participants are supported in looking for evidence and also validated in their challenges to make sense of confusing experiences. Their experience is normalized, helping them to feel less alone in their journey. They are given hope through a here-and-now, problem-solving method in which they are their own experts in the search for meaning and understanding. Together these pieces allow clients experiencing psychosis to lead more functional lives, far from their previous disconnected and disorganized realities. The framework that CBTp offers to both clinicians and clients within the clinical setting can also be beneficial in more global contexts. Perhaps if our society learned to be more open, accepting, and validating towards individuals with psychosis, we could move away from stigma and towards community acceptance and understanding that individuals who experience psychosis can and do recover.
- Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York, NY: Guilford Press.
- National Institute for Health and Care Excellence (NICE). (2014). Psychosis and schizophrenia in adults: Prevention and management. Retrieved from: https://www.nice.org.uk/guidance/cg178
- Kreyenbuhl, J., Buchanan, R. W., Dickerson, F. B., & Dixon, L. B. (2010). The schizophrenia patient outcomes research team (PORT): Updated treatment recommendations 2009. Schizophrenia Bulletin, 36(1), 94–103.
- Kingdon, D. G., & Turkington, D. (2005). Cognitive therapy of schizophrenia. New York, NY: Guilford Press.
- Morrison, A. P. (2001). The interpretation of intrusions in psychosis: An integrative cognitive approach to hallucinations and delusions. Behavioral and Cognitive Psychotherapy, 29, 257–276.
Deal, S., & Alt, V. (2016). A Curious Lens: Cognitive Behavioral Therapy for Recovery and Resiliency. Focal Point: Youth, Young Adults, and Mental Health, 30, 22-24. Portland, OR: Research and Training Center for Pathways to Positive Futures, Portland State University.