Cognitive Behaviour Therapy

The Ten Essential
Shared Capabilities

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Cognitive behaviour therapy (CBT) is the name given to a broad range of therapeutic approaches to psychological distress. The main assumption in CBT is that emotional problems depend on how people think and behave. Change in distress is brought about by changing thinking patterns and by changing behaviour. There is now considerable evidence as to the efficacy of CBT in dealing with a variety of emotional problems such as anxiety and depression. In recent years CBT has been applied to psychotic experience.

CBT is based on an assessment of an individual and a formulation of that individual's difficulties. When applied to psychotic experience CBT would have a number of elements:

Coping strategies for psychotic symptoms

For example some people find strategies such as distraction e.g. reading aloud, listening to music helpful.

Dealing with delusional beliefs and beliefs about voices

Therapy would address people's beliefs about their hallucinations - what they are, where they come from, what they say. Such beliefs have been clearly demonstrated to be associated with levels of distress (Chadwick et al., 1994) [25].

Individuals tend to become more distressed if they belief their voices are a manifestation of a powerful malevolent source, rather than, a symptom of mental illness, or a product of traumatic experience.

CBT would also address delusional beliefs. Therapy would not confront these beliefs directly but creates a forum in which the evidence for and against these beliefs are examined and alternatives discussed.

Dealing with beliefs about the self and others

Most clients who have been diagnosed with severe mental illness hold unhelpful beliefs about themselves (e.g. low self esteem) and the world in which they live. Such beliefs tend to underpin most forms of psychological distress. Again therapy would hope to alter these beliefs by creating a forum in which they are examined and analysed.

CBT is a tried and tested intervention for many forms of emotional distress. Within the realm of severe mental illness several randomised controlled trials now exist (Kuipers, et al., 1998; Sensky et al., 2000). Overall results are positive; for example, Kuipers et al. (1998) reported a 25% reduction in symptoms severity. Approximately 50% of all people involved in the trial benefited.

Family Interventions

Research has revealed an important role the family can play in helping in the recovery of a person with psychotic experiences. In particular, attitudes of friends and relatives towards the person, and how they understand and react to the person's experiences are very important. They can also influence the extent to which the person is able to recover.

Family Relationships

The evidence is now fairly clear, and has been repeated on many occasions, that family members' attitudes can affect the outcome for people diagnosed with schizophrenia or bipolar disorder. There are two important aspects to this .

The first is that friends and relatives occasionally find dealing with some of the problems that can be associated with psychotic experiences (particularly embarrassing , socially disruptive or socially withdrawn behaviour) frustrating and difficult, and sometimes become critical or actively hostile towards the individual.

The second reaction is to find the changes very upsetting and to try to look after the person rather as if they we re a child again. While this ' emotionally over- involved' reaction is understandable and can be helpful in the short term, during recovery it can lead to dependence in the individual and exhaustion in the carer. Either or both of these attitudes in carers (i.e. criticism or over- involvement) have been described as ' High Expressed Emotion'. If they become extreme, they have been found to lead to poorer outcome and an increased likelihood of a return of psychotic experiences. In contrast, people living in more supportive, tolerant , low Expressed Emotion environments tend to have a lower likelihood of a return of psychotic experiences, better social functioning, and better outcome.

Perhaps unsurprisingly, relatives who find caring particularly stressful also tend to have high levels of Expressed Emotion. The way someone's psychotic experiences are understood and explained by their friends, relatives and other people helping them is very important, and can help determine the extent to which they are able to recover.

The most long-standing and best-evaluated psychosocial intervention aimed at reducing stress in the environment has been family intervention. Research has consistently demonstrated that family environments have a significant role in precipitating relapses in vulnerable individuals. People diagnosed with schizophrenia from families that express high levels of criticism, hostility, or over-involvement, have more frequent relapses than people with similar problems from families that tend to be less expressive with their emotions (Vaughan et al., 1976).

There is good and consistent evidence from methodologically sound clinical trials that family intervention in conjunction with prophylactic medication dramatically reduces relapse rates, rehospitalisation and reduces costs to services (Penn & Mueser, 1996; Pharoh et al., 2000). The main purpose of family intervention is to reduce the levels of distress within the family and to improve the quality of family relationships. The main components of family work depend upon the needs of a particular family however intervention mainly involves education about schizophrenia, problem solving, stress management and communication training.

Not all people who have psychotic experience live with their families. It is likely that relationships with staff are likely to have the same effect in terms of relapse. This suggests that mental health teams member need to train, supervise and support staff carers to reduce the potentially negative effects of unhelpful relationships. [3]

The Stress-Vulnerability Model

As in most areas of human life, research into the causes of psychotic experiences indicates that both biological and environmental factors are important. As might be expected, these two broad types of factors interact.

Moreover, no one single cause has been identified, and it is likely that many aspects of an individual's life are significant in producing psychotic experiences. This idea has been described as the 'stress-vulnerability' model. In the stress-vulnerability model, it is suggested that everybody has a different level of vulnerability to the development of psychotic experiences. People are believed to be more or less vulnerable as a result of both biological factors (which could well be the result of either genetic factors or biological changes following birth) and psychological factors (for instance, being very sensitive - or resilient - to stress in a psychological rather than biological sense). Sensitivity to particular stresses may, of course, be at least partly a result of events that have happened previously in the person's life. [6]

In the stress-vulnerability model, it is suggested that vulnerability will result in the development of problems only when environmental stresses are present. If the vulnerability is great, relatively low levels of environmental stress might be enough to cause problems. If the vulnerability is lower - the individual is more resilient - problems will develop only when higher levels of environmental stress are experienced. This model explains why some people develop problems and others do not, even when they go through similar traumas . It explains why extreme stress can lead to psychotic experiences in almost anyone. It helps explain why some people recover from psychotic experiences faster than others, and are less likely to experience a reoccurrence of their problems .

It also offers the continuing possibility of recovery over time; as even those with the most difficult problems may be able to avoid or reduce the likelihood of further episodes by finding ways of reducing their exposure to situations that they find particularly stressful . The model also acknowledges the idea of psychotic experiences being on a continuum with other psychological problems such as anxiety. Finally, it also tries to explain the fact that people who are prone to psychotic experiences may have long periods of recovery, but may develop new difficulties ('relapse') at various times. [5]

Other Therapeutic Approaches

Many different psychological, psychosocial and psychotherapeutic schools and approaches exist. These approaches have many things in common and are all based on a collaborative and trusting relationship between the client and therapist. It is likely, however, that not all approaches are effective for all people. Approaches other that a cognitive behavioural one may well be more suitable to some individuals with psychosis. There is, however, paucity of evidence as to the effectiveness of other approaches to severe mental illness and a paucity of research attempting to identify which approach might suit which individual.

Of crucial importance is that in any approach taken, no matter what the therapeutic allegiance, the intervention should be based upon a trusting, collaborative working relationship in which the person is seen as the expert in their care, with the expectation that they are central to all decisions made about their care. [3]