Cognitive · 1994
Cognitive Behavioural Therapy for Psychosis (CBTp)
Change comes about when the psychotic experience loses its rigid meaning of threat and the person recovers the capacity to understand and cope with it.
Cognitive Behavioural Therapy for Psychosis (CBTp) is an adaptation of classical cognitive therapy applied to people with schizophrenia and other psychotic disorders, focused on reducing the distress associated with delusions, hallucinations and unusual experiences rather than on eliminating them directly. The model starts from the premise that interpretations, metacognitive beliefs and coping styles influence the intensity of suffering and the behaviour associated with psychotic symptoms. Through collaborative assessment, normalisation, behavioural experiments and work with voices and delusional beliefs, CBTp seeks to increase cognitive flexibility, improve emotional regulation and strengthen agency, complementing pharmacological treatment and rehabilitation programmes.
Theory of change
A person changes when they can reinterpret their psychotic experiences in a less threatening way, recover agency and respond to them with greater flexibility.
Core ideas
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Psychotic distress depends on the meaning attributed to the experience
CBTp holds that hallucinations and delusional beliefs do not generate suffering solely by their presence but through the interpretation the person makes of them (for example, threat, persecution or external control). The intervention focuses on modifying the meaning and the associated conviction, not necessarily on eliminating the perceptual phenomenon. (Kingdon & Turkington, 2005).
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Direct confrontation of the delusion is usually counterproductive
The model emphasises collaborative empiricism rather than confrontation about the truth of the delusion. Challenging the belief head-on can increase mistrust and resistance; gradual exploration, shared formulation and the generation of alternative hypotheses are therefore encouraged. (Kingdon & Turkington, 2005; Turkington et al., 2006).
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The therapeutic alliance is a condition of possibility in psychosis
Because of the frequent presence of suspiciousness and persecutory experiences, the alliance in CBTp is not merely facilitative but structural. Without a sufficiently trusting bond, the cognitive work can neither be sustained nor generalised. (Kingdon & Turkington, 2005).
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Psychotic experiences exist on a continuum with normality
CBTp adopts a dimensional model in which hallucinations and unusual beliefs are understood as extremes of cognitive processes present in the general population under certain conditions of stress or vulnerability, thereby reducing stigmatisation and facilitating a comprehensible formulation. (Kingdon & Turkington, 2005).
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Cognitive flexibility matters more than the disappearance of the symptom
The therapeutic aim is not necessarily to eliminate delusions or voices but to reduce their conviction, the power attributed to them and the distress associated with them, increasing the patient's capacity to consider alternative explanations and to act functionally. (Turkington et al., 2006).
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Core beliefs about the self influence psychotic content
CBTp recognises that core schemas of vulnerability, inferiority or threat can shape the content of delusions and hallucinations, so that work on self-esteem and self-concept is an integral part of the treatment. (Kingdon & Turkington, 2005).
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Experiential learning modifies delusional convictions
Behavioural experiments make it possible to generate direct evidence that contradicts predictions associated with the delusion, fostering a progressive weakening of conviction through experience and not only through logical argument. (Kingdon & Turkington, 2005).
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Emotional regulation modulates the intensity of the symptom
Physiological arousal and anxiety increase the likelihood of persecutory or catastrophic interpretations; training in emotional regulation and the reduction of arousal is therefore an essential part of the approach. (Turkington et al., 2006).
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CBTp complements, rather than replaces, pharmacological treatment
The model is conceived as a psychological intervention complementary to antipsychotics and psychosocial rehabilitation, improving coping, adherence and overall functioning without denying the neurobiological basis of psychosis. (Kingdon & Turkington, 2005).
Influences
- Cognitive therapy (depression)
- Psychosis
- Rehabilitation
- Representational rationalism (classical cognitivism)
- Objectivist empiricism / Logical positivism
Key references
- Kingdon, D. G., & Turkington, D. (2005). Cognitive Therapy of Schizophrenia.
- Turkington, D., Kingdon, D., & Weiden, P. (2006). Cognitive Behavior Therapy for Schizophrenia.
- Tarrier, N. (2005). Cognitive Behavior Therapy for Schizophrenia.