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The Role of Psychology in Treating Psychosis

What is psychosis

Psychosis refers to a collection of symptoms that affect the mind, where there has been some loss of contact with reality. During an episode of psychosis, a person’s thoughts and perceptions are disrupted, and they may have difficulty recognising what is real and what is not.

Wonny

Author: Wonny Kim

Brisbane Clinical Psychologist

Hallucinations vs. Delusions

People with psychosis typically experience delusions and hallucinations. They might also speak in a way that’s hard to understand (incoherent or nonsensical speech) or behave in ways that do not seem to fit the situation.

  • Delusions are strong beliefs that aren’t based in reality, and people hold on to them even when there’s clear evidence they’re not true. These beliefs can take many forms, such as:
  • Persecutory delusions - believing that someone or some group is out to harm or harass them. This is the most common type.
  • Referential delusions - thinking that random things like TV shows, gestures, or signs are specifically meant for them.
  • Grandiose delusions - believing that they have special powers, are extremely important, rich, or famous.
  • Erotomanic delusions - thinking that someone (often a stranger or famous person) is in love with them.
  • Nihilistic delusions - believing that a major disaster is going to happen, or that they or the world no longer exist.
  • Somatic delusions - being overly worried about their health or believing something is wrong with their body, even when there’s no medical reason.

Hallucinations are seeing, hearing, or sensing things that aren’t actually there. These experiences feel very real to the person and aren’t under their control. Hallucinations can affect any of the senses, but hearing voices is the most common type, especially in conditions like schizophrenia.

Voice hearing statistics

Around 5-15% of people will hear voices at some point in their lives. In Australia, around 3.7 million people hear voices, and in the world, approximately 1.1 billion people have had a voice hearing experience.

Meaningful aspects of voice hearing

  • Voices can highlight an emotional need.
  • Voices can provide company and ease loneliness.
  • Voices can help to resolve unprocessed grief.
  • Voices can strengthen spiritual connections.
  • Voices can help identify and work through past traumas.
  • Voices can provide a creative outlet for the mind.

Cognitive Behavioural Therapy for Psychosis (CBTp)

Individuals with psychosis often experience residual or persistent psychotic symptoms despite receiving adequate pharmacotherapy.

Cognitive Behavioural Therapy for Psychosis (CBTp) is an evidence-based treatment approach shown to improve symptoms and functioning for individuals with psychotic disorders. The treatment aims to enhance function despite difficult symptoms and experiences. CBTp has been recommended as a frontline treatment in guidelines for schizophrenia published by the American Psychiatric Association (APA), Patient Outcomes Research Team (PORT), and the National Institute for Health and Care Excellence (NICE) in the United Kingdom.

CBTp is a structured and goal-based treatment that can be delivered in individual and group modalities and has long-lasting benefits after the completion of therapy. For individual therapy, the recommended duration for therapeutic gains is 16 sessions and 24 for group therapy.

Components of CBTp Interventions

  • Normalisation -Helping people understand that having unusual thoughts or hearing voices isn’t as rare as it might seem. Many people, even those without a mental illness, can have similar experiences, especially under stress.
  • Risk assessment and safety planning - particularly if individuals experience voices that tell them to harm themselves.
    Building awareness and insight (can be helpful to utilise a voice diary).
  • Identifying triggers and early warning signs to reduce them.
  • Creating a voice profile - exploring the voices they hear, how many there are, what they say, who they sound like (if the person knows the voices), and how they make the person feel.
  • Recognising and working through cognitive distortions/unhelpful beliefs about their psychosis, e.g., “they will never stop”, “I have no control”. Identifying how they can gain back the control, e.g., assertiveness skills and self-compassion work.
    Identifying protective factors and strengths.
  • Socratic questioning and checking the facts around certain beliefs - and behavioural experiments.
  • Enhancing self-esteem. Experiencing psychosis can impact how the individual sees themselves, particularly if they experience punitive voices.
  • Engaging in meaningful activities. Finding out what truly matters and working towards an enriched life.
  • Relapse prevention/staying-well plan.

Resources for Clinicians

Therapy manuals

  • Cognitive behavioural therapy for psychosis (CBTp), An introductory Manual for Clinicians by Yulia Landa
  • Psychotherapy for Psychosis (Integrating Cognitive-Behavioural and Psychodynamic Treatment) by Michael Garrett

Group CBTp guidebook

Brief assessment tools

  • Brief Psychiatric Rating Scale (BPRS)
  • CHOICE (scale to help identify what the individual wants to work on psychologically)

Resources for Clients

Reference