Is cognitive-behavioural therapy a worthwhile treatment for psychosis?

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Abstract
Patients with schizophrenia and their carers have tended to be the passive recipients of care delivered by mental health services. This situation has largely developed because of the negative results reported with psychodynamic psychotherapy and the failure to implement family therapy interventions proven to reduce relapse. Cognitive–behavioural therapy as applied to schizophrenia has become increasingly available across the UK over the past 10 years. It has been welcomed by patients and carers alike because it brings them into the treatment team as active participants in the management of psychotic symptoms. The therapy primarily facilitates engagement and the establishment of collaborative empiricism, with reality-testing based on guided discovery rather than confrontation or collusion. This working relationship allows for the testing and working-through of hypotheses concerning causation and maintenance of distressing symptoms. Hallucinations, delusions, negative symptoms and depression have all been shown to be responsive to CBT ( Sensky et al, 2000). Techniques range from more-superficial peripheral questioning of delusional content to deeper work on underlying dysfunctional beliefs about the self (e.g. ‘I am evil, deficient, damaged’ or ‘I am special, unique, different’). Homework exercises allow patients, often with the help of key-workers or carers, to begin to make sense of their distressing experiences and to see the effects of working on avoidance, rational responding or changing coping strategies. Cognitive–behavioural therapy is therefore an individualised intervention based on a case formulation which helps the patient to answer the question, ‘Why have I changed so much?’ and to begin to see the point in taking medication and attending social treatment options. Such improvements in insight and adherence have led to reductions in relapse and rehospitalisation. Carers who have worked in this way have often moved from the expression of frustration and guilt to a more hopeful and less alienated position.