Cognitive Behavioral Therapy for Psychosis (CBTp)

Structure of CBT Session

  • Agenda Setting - 2 Mins
  • Homework Review - 5-10 Mins
  • Clinician Item and Homework setting - 15 mins
  • Client Item - 15 Mins
  • Feedback - 2 Mins

Catch it, Check it, Change it


  • Trigger(Makes the problem more likely to happen - eg. having an argument with my partner) & Modifier(Makes the problem better or worse - eg. Sleep, mood)
  • Precipiter(Something that happened - significant life event)
  • Beliefs
    • Vulnerability Factors(Genetics, childhood trauma)
  • Maintenance
    • Treatment Targets

Common Maintenance Processes

Things that keep a Psychosis going on

  • Safety Behaviors and Avoidance - if something is frightening, we avoid it
  • Reduction of Activity - stay in all day when depressed
  • Catastrophic Misinterpretations -
  • Self fulfilling prophecies
  • Performance Anxiety
  • Fear of Fear
  • Perfectionism
  • Short-Term Rewards - substance use, self harm

Different mental health issues as viewed by CBT

  • Psychosis: traditionally discussed as the difficulty in distinguishing what is real from what is not real.

  • Delusion: fixed false beliefs held in the face of contrary evidence

  • Depression -> distorted beliefs about self worth & Efficacy

  • Anorexia -> fixed false belief about being overweight

  • Panic Disorder -> Distorted belief about physical safety

  • OCD -> Distorted beliefs - thought-action fusion

Psychosis is characterized by culturally unacceptable interpretation of experiences

  • Stigmatizing and distressing => Maintains Psychosis


  • Normalizing may reduce stigma and distress
  • CBT techniques might be successful in psychosis too.

Eg. 2 woman feel a lump in their breast, one gets test that says its benign - but still believe that its cancer. Other thinks that its a govt. installed thought monitoring device. Second woman is said to have psychosis.

Self-Regulatory Executive Functioning Model

CBT Theory of Auditory Hallucinations(AHs)

AHs are mis-attributed internal events(Eg. verbal thoughts, inner speech)

Individuals with psychosis are...

  • Less likely to recognize thoughts as their own
  • Less likely to recognize own voice played back with minor distortions
  • Tend to assuming that ambiguously sourced info was generated externally

Goal might not be to remove distorted belief entirely - reduction of conviction can be very helpful

Types of Homework

  • Information Collection
    • Current Functioning
    • Current Symptoms, experiences, thoughts, affactive states, etc.
    • Track substance use and relationship to symptoms
  • Experiments
    • Discover what happens when client thinks/behaves differently
    • Exploration of different outcomes from different actions
  • Practice New Skills
    • Intense Repetition is necessary for behavior change

What to choose for homework: 3 R's

  • Is it Relevant
    • To the model
    • To the case conceptualization
    • To the content of the session
    • To the clients goals
  • Is it Realistic
    • Is it achievable
    • Is it challenging enough to feel significant but not so difficult that its impossible
  • Is it the clients Responsibility
    • Is it within the client's control
    • Is it the clients responsibility to address

Homework should be chosen by both therapist and the client

  • Ensure client understands the rational
  • If client does not do the homework...
    • Do not shrug and move on - find out why
    • Be curious, not confrontational
    • Involve support network/family