CBT for psychosis and for command hallucinations

Domain II · Behavioural & cognitive · Fowler, Garety, Kuipers · 1995 · London

What it is

CBTp is a one-to-one, formulation-driven talking therapy for people with distressing psychotic experiences (voices, unusual or paranoid beliefs) and the distress, low mood and disability around them. It does not aim to remove symptoms by argument. It links the person's experiences, appraisals,…

Format

• Format and dose.
• NICE CG178: individual CBTp delivered one-to-one over at least 16 planned sessions, following a treatment manual, offered to everyone with psychosis or schizophrenia (first episode, later episodes and for recovery), alongside family intervention where possible.

Evidence status, as the guide reports it

• The trial papers name four belief targets rather than numbered phases: (1) the voice's absolute power and control; (2) the belief that one must comply or appease or be severely punished; (3) the voice's identity, e.g. the Devil; (4) the meaning of the voice experience, e.g. punishment for past…

Questions to explore with your client

• What drew you to it, and what are you hoping it will change?
• Does it involve any substance, plant preparation, remedy or supplement? Has your doctor or prescriber been told, especially about any medication you take?
• Does it involve intense or unusual breathing? Have you been told about the medical conditions for which that is not advised?
• Does it involve fasting, a special diet or 'detox'? Have you discussed this with your doctor?
• Is it a group, retreat or community? How do they respond if someone wants to leave or raises a concern?
• Who runs it, and what training or registration do they hold?
• What actually happens in a session or meeting, and how often?
• What does it cost, and is there pressure to commit to more?
• How do you feel afterwards, in the hours and days that follow?
• Does it fit with, or clash with, the work we do here?

What practitioners of it watch for

• discounting of successes. Use a written log.
• relapse during life stressors. Rehearse with a likely scenario.
• sedation or negative symptoms limiting uptake. Use very small steps.
• loss reactions or symptom flare-ups as therapy ends. Plan for them in advance.
• vague, unfalsifiable predictions. Help the person pin down specifics in advance.

When to involve someone else

• New or worsening physical symptoms, or advice to stop or change prescribed medication: involve the client's doctor or prescriber.
• Signs of coercion, isolation from family and friends, escalating costs or secrecy: discuss openly and consider safeguarding.
• A crisis or thoughts of suicide: follow your crisis protocol. In the US, call or text 988; in the UK and Ireland, Samaritans on 116 123.

Drawn automatically from the guide's own sections. Stay curious: neither endorse nor dismiss what the client values, and check anything that matters against the full guide and its sources. Not medical advice.