Cognitive Behavioral Therapy as Adjunctive Treatment for Psychosis

As mindfulness and CBT make their way into mainstream medicine, there are many hurdles to clear. We need to accomplish more research on the anatomical correlates, neural substrates and cognitive descriptions. We will also need to educate more healthcare practitioners who, until now consider illnesses such as psychosis as untreatable, especially since CBT has been shown to be effective.

I expect that as long as the discussion is geared toward the use of CBT as an adjunct to standard therapy, then the possibilities are limitless. This is true for a few reasons. First, professions as a group tend to be territorial regarding their area of expertise. Psychiatrist, for instance tend to resist the idea of psychologists gaining the authority to write drug prescriptions, and orthopedic physicians raise an eyebrow when podiatrists treat above the leg bone. An integrated approach; however, ensures that the patient will remain the center of attention in the process.

Second, we must be willing to recognize the potential limitations of CBT as it applies to the treatment of mental illness in general and specifically psychosis. The most obvious limitation is the possibility that the patient will see the therapist as part of the delusional belief system. In this case, the therapist is all but impotent in the attempt to establish credibility. Another limitation is when the patient does not possess the cognitive ability to think linearly and logically. Still on the topic of limitations, we must also work to eliminate the limitations of some of our health care professionals as it relates to their views on the “futility of treatment” of psychosis.

To this point, an argument made by Antonia Pinto in his Clinical Handbook of Mindfulness is “as long as therapists consider patients’ main psychopathological symptoms (delusions, hallucinations and bizarre behaviours), as nonsensical, hard to investigate and therefore hindrances to therapy, they will inevitably convey to patients, intentionally or not, the idea that they will not actually improve until they come around to the fact that delusions and hallucinations are the core issues of their disease. Patients are indeed likely to make a stand against this, further complicating the formation of a therapeutic alliance.”¹

Returning to a meta-cognitive learning method that I detailed in my article “How does Mindfulness in Cognitive Behavorial Therapy Help you”², I believe that there are corollaries that could be applied to the treatment of psychosis with CBT. My technique for studying difficult subject matter was to write the information down on notecards with a question on one side and the answer on the other. I would also read the text on both sides into a voice recorder.

“My strategy was that I more likely to retain the information if I allowed my brain to process it using as many senses as possible. That is to say, I read it (visual), spoke it aloud (muscle memory of the tongue), and listened to the recorded Me (auditory). To boot, I found that I responded positively to the recorded Me affirmation even though I knew it was Me. It turns out that my brain (and yours) likes to hear nice things spoken abound me regardless of the source. If you disagree, think about the last time you gave yourself a pep talk just before a difficult undertaking, or talked yourself into getting out of bed in the morning.”

Returning to my earlier thought about how the corollary of my experience should be applicable to psychosis treatment-- Since a defining characteristic of psychosis the patient’s inability to distinguish the subjective experience of hallucinations and delusions from the real world—why not consider giving up on the idea of changing their thoughts and concentrate on changing their relationship to the thoughts. Specifically, the brain should be capable of objectively exploring the evidence for and against the unhelpful belief. In this way, it is able to interpret what is happening. In the event I am able to identify sufficient evidence, I must then be willing to explore the possibility of doubting its reliability.

Studies have been performed on this topic that I believe demonstrate the limitations and potential of CBT treatment of psychosis. One particular paper that dealt with First Episode Psychosis (FEP)³ was particularly interesting because of the method they used to distinguish subject categories within the study. In their paper the authors described their attempt to discern “what patient characteristics influenced clinicians' decision to refer or not to refer to group cognitive behavioural therapy for FEP and what characteristics were associated with those referred attending/not attending and adhering/not adhering to the programme.”⁴

Their conclusion was “within an early intervention service for FEP, it appears that individuals with less education, more negative symptoms and less insight experienced significant barriers to successfully completing group CBT.” The authors made the salient point that it might be worthwhile to perform a more assertive outreach program that includes providing referring clinicians with CBT information. In short, we need to get the word out.

Resources

¹ Pinto, Antonio. Mindfulness and Psychosis. Clinical Handbook of Mindfulness. Springer Science, LLC  2009

² Brown, Tony “How does Mindfulness in Cognitive Behavorial Therapy Help you” www.psychologymatters.asia.com

³ Fanning F, Foley S, Lawlor E, McWilliams S, Jackson D, Renwick L, Sutton M, Turner N, Kinsella A, Trimble T, O'Callaghan E. Group cognitive behavioural therapy for first episode psychosis: who's referred, who attends and who completes it? Early Interv Psychiatry. 2012 Jan 13. doi: 10.1111/j.1751-7893.2011.00333.x. [Epub ahead of print] PubMed PMID: 22240156

⁴ Fanning F, Foley S, Lawlor E, McWilliams S, Jackson D, Renwick L, Sutton M, Turner N, Kinsella A, Trimble T, O'Callaghan E. Group cognitive behavioural therapy for first episode psychosis: who's referred, who attends and who completes it? Early Interv Psychiatry. 2012 Jan 13. doi: 10.1111/j.1751-7893.2011.00333.x. [Epub ahead of print] PubMed PMID: 22240156