What sort of symptoms can CBT for psychosis help?

Dr Emmanuelle Peters: The sorts of experiences – unusual and distressing experiences – that people will come to us with will be hearing voices, for instance, or sometimes hearing sounds or music which they find distressing – these may be voices telling them what to do and they may be telling them things that they don’t want to do, such as harming themselves, or harming others occasionally, although more often than not harming themselves.

There may also be distressing beliefs, paranoia being a very common one, thinking that people mean them harm in some way, that they are being ridiculed or mocked or actually that people are going to kill them or attack them and harm them in some way.  

You also have experiences that we would call ‘thought disturbances’, for instance believing that people can read your mind or that you can project your thoughts onto other people, or that other people’s thoughts are coming into your mind which are not your own. People can have quite elaborate beliefs sometimes.  I remember once meeting someone who thought that the birds were communicating with him, and with everybody else around them, but that only this person could decode the messages from the birds. The particular hospital we were in was in the countryside, so there were lots of birds around and it was extremely difficult for this person to function. He was constantly receiving messages from the birds and thinking that he had to do something to save everybody else from the conspiracy that the birds were in charge of.  And it can be all sorts of distressing beliefs – some people feel they’ve been cloned by aliens, or that they have special missions or powers which lead them to do extremely dangerous things.

What we know we can’t do is get rid of people’s hallucinations, for instance, but we know that we can help reduce distress and we can help reduce the interference that they cause in people’s lives, and we know that we can also help with reducing compliance with hallucinations, for instance – people who do things that they don’t want to do because of the voices.  And we also know that we can reduce distress and preoccupation with delusions, for instance. You can’t change conviction with everybody – some people would still carry on believing what they are believing, but they’ll just be less distressed and preoccupied by it.  

People with psychosis usually have a myriad of secondary difficulties, the most prominent of which are emotional problems.  And of course, for some people they cope very well with having voices, it’s become part of their lives and they can negotiate with them and deal with them, but what they can’t cope with is, for instance, depression – so the despair of waking up every morning, and not having any kind of socially valued role.

They have no relationships, they have no job, they have very little to occupy themselves and they are stigmatised by society, and you find that that is something that can be more painful and distressing for the person than actually their classic psychotic experiences. There is lot of social anxiety in psychosis so we may also be dealing with that, but of course it’s quite different to the work that you would be doing with somebody who has straight social anxiety because in that person, it’s likely to be complicated by their voices, or feeling of paranoia and other complicating factors. 

The strongest evidence for CBT for psychosis is that it helps with depression, and in the clinic that I run, I would say that up to 50 per cent of the people that we have referred, their predominant problem will be an emotional disturbance such as depression or anxiety, and that is what we will address if that’s what the person puts as their priority. But often it’s complicated by the ongoing symptoms of psychosis that may be going on, which is why it’s still important for them to be coming along to someone who is specially trained in CBT for psychosis, because it’s more complicated than just straightforward depression work.