Abstract
Cognitive Behavioral Therapy for psychosis (CBTp) is an evidence-based intervention that supports individuals in understanding and transforming distressing beliefs, voices, and unusual experiences. This article outlines a structured, recovery-oriented, and experiential model of CBTp, grounded in the principles of cognitive restructuring, collaborative formulation, and behavioral experimentation. The first three sessions are detailed, emphasizing engagement, shared understanding, and initial cognitive interventions that promote empowerment and insight. With a focus on hope, agency, and dignity, this article offers clinicians a practical framework for applying CBTp across various stages of psychosis.
Keywords
CBT for Psychosis, CBTp, Recovery-Oriented Therapy, Cognitive Restructuring, Voices, Delusions, Engagement, Mental Health
Introduction
Psychosis is often associated with fear, stigma, and chronic impairment. However, research over the past two decades has shown that targeted psychotherapeutic interventions can help individuals live meaningful lives while managing unusual beliefs, hallucinations, and emotional dysregulation (National Institute for Health and Care Excellence [NICE], 2014; Morrison et al., 2014). Cognitive Behavioral Therapy for psychosis (CBTp) is a structured, collaborative, and evidence-based intervention designed to reduce distress, challenge unhelpful thinking, and promote recovery. This article introduces a practical, session-based framework to support clinicians in delivering CBTp with hope, skill, and purpose.
Method and Framework
CBTp is not aimed at eliminating psychotic symptoms, but at helping individuals change their relationship to them. This includes:
- Building therapeutic engagement and a shared understanding of experiences
- Collaborative case formulation
- Cognitive restructuring and behavioral experimentation
- Normalizing psychotic experiences and promoting alternative perspectives
- Encouraging values-driven action and meaning-making
The approach is person-centered, strengths-based, and tailored to individual insight, stage of illness, and cognitive capacity.
Session-by-Session Application
Week 1: Engagement and Collaborative Understanding
The first session focuses on creating a safe, nonjudgmental space. The therapist explores the client’s goals, preferred language for describing their experiences, and hopes for the future. A basic 5-Area CBT model is introduced to begin mapping the person’s experiences. Emphasis is placed on shared curiosity, autonomy, and transparency. The clinician avoids directly challenging beliefs in this session and instead focuses on validation, exploration, and alliance-building.
Week 2: Case Formulation and Meaning-Making
Using the person’s narrative, a personalized case formulation is co-created. The formulation includes potential triggers, beliefs, emotions, behaviors, and maintenance factors. For example, hearing voices may be linked to trauma, social isolation, or anxiety. The clinician introduces normalization strategies, explaining how many people experience voices or unusual beliefs. The formulation is used to shift the framework from ‘what’s wrong with you’ to ‘what happened to you and how did you learn to survive?’
Week 3: Cognitive Work and Alternative Explanations
In the third session, the therapist begins gentle cognitive restructuring, often using Socratic dialogue to explore evidence for and against specific beliefs. For example, a client who believes they are being watched may examine the evidence and consider alternative interpretations. Behavioral experiments may be introduced in low-stress scenarios. The aim is not to prove the client wrong, but to increase flexibility in thinking and reduce the emotional impact of the belief.
Discussion
CBTp requires deep respect for the lived experience of psychosis. Rather than focusing solely on symptom reduction, the emphasis is placed on personal meaning, resilience, and self-determination. The early sessions are foundational: they set the tone for collaborative work, increase safety and insight, and offer clients new ways of understanding themselves and their minds. The therapist’s stance—curious, validating, and non-confrontational—is central to success.
Conclusion
CBT for psychosis represents a paradigm shift—from pathology to possibility. Through structured, collaborative, and compassionate sessions, individuals can gain insight, reduce distress, and reconnect with their goals and values. These first three sessions establish the therapeutic foundation for recovery, dignity, and transformation.
References
- Morrison, A. P., Turkington, D., Pyle, M., Spencer, H., Brabban, A., Dunn, G., … & Hutton, P. (2014). Cognitive therapy for people with schizophrenia spectrum disorders not taking antipsychotic drugs: A single-blind randomized controlled trial. The Lancet, 383(9926), 1395–1403.
- National Institute for Health and Care Excellence. (2014). Psychosis and schizophrenia in adults: prevention and management. Clinical guideline [CG178].
- Turkington, D., Kingdon, D., & Weiden, P. J. (2006). Cognitive behavior therapy for schizophrenia. American Journal of Psychiatry, 163(3), 365–373.
- Rathod, S., Phiri, P., & Kingdon, D. (2010). Cognitive behavioural therapy for schizophrenia. Psychiatric Clinics, 33(3), 527–536.
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