Cognitive behaviour therapy

• What is cognitive behaviour therapy?
• Does CBT help people who have experienced psychosis?
• How do you know it works?
• Who are the therapists?
• Can everyone who has experienced psychosis access CBT?

What is cognitive behaviour therapy?

Cognitive behaviour therapy (CBT) is a type of talking therapy that aims to help people manage their problems by looking at the way they think, how their thoughts affect their feelings and actions, and how their actions affect their thoughts.

The therapy can help people change how they think and what they do to make them feel less distressed. CBT addresses today’s problems and difficulties, rather than only looking into the past, as some other forms of therapy do.

CBT can be adapted to help people with specific mental health problems. Different versions of CBT have been developed for people who have experienced the symptoms of psychosis, for people who have depression, anxiety, obsessive compulsive disorder and post traumatic stress disorder, for example. CBT can also help people who have physical health problems.

People can have CBT individually or in groups. There are self-help versions available for some problems, and also computer programmes – Beating the Blues, for example, is offered by some NHS services to people who have mild to moderate depression.

A course of CBT can last from six weeks to six months, and longer for some people, depending on the type of problems.

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Does CBT help people who have experienced psychosis?

Cognitive behavior therapy for psychosis, given in addition to medication, can help people cope better with some of the experiences they have – voices and delusions, for example – that may be causing them distress.

Therapists help people try to understand their hallucinations and any upsetting and worrying thoughts and beliefs, and discuss new ways of thinking about them, and dealing with them. CBT doesn’t necessarily get rid of the symptoms or upsetting experiences, but it can help people cope better and lessen the distress that some symptoms can cause. The therapy focuses on the priorities of each individual: people come to the sessions with a list of problems that they and the therapist can then work on together.

CBT can also help with the depression, anxiety, lack of motivation and low self-esteem often experienced by people who have a diagnosis of schizophrenia.

However, cognitive behaviour therapy does not help everybody who has experienced psychosis. Generally, only people who want therapy and engage fully in the process are likely to be helped. Therapy cannot be imposed on people, and an individual has to be motivated to meet with a therapist.

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How do you know it works?

A lot of research has been carried out to test the effectiveness of CBT for psychosis.

Researchers at the Institute of Psychiatry and health professionals working at South London and Maudsley NHS Foundation Trust were among those who pioneered CBT for psychosis some years ago and carried out a series of studies that showed the talking therapy made a positive difference.

Since then, research from the UK, Europe, the USA and Canada has continued to illustrate that CBT can help reduce the symptoms of psychosis and depression experienced by people who have a diagnosis of schizophrenia. The research shows that CBT works best for people who are relatively stable and taking medication, but who have ongoing distressing symptoms.

Research carried out with people with bipolar disorder has shown that CBT can help speed recovery from depression and help prevent relapse.

New forms of CBT are being developed – for example to help people deal with specific symptoms of psychosis, such as ‘command’ voices (voices that tell people to carry out harmful actions); to help people cope with the early symptoms of psychosis. Recovery-focused CBT for people who have a diagnosis of bipolar disorder is being developed and evaluated and a version of CBT for children and young teenagers who are having unusual psychotic-like experiences – such as hearing voices – is currently been trialled.

Research has also been carried out to see if CBT can help people who have a diagnosis of schizophrenia who are not taking antipsychotic medication. A very small study carried out by the Psychosis Research Unit in Manchester (University of Manchester and Greater Manchester West Mental Health NHS Foundation Trust) has shown that CBT for psychosis did help people who had not been taking medication for at least six months. Now the same research team is carrying out a larger trial to find out what difference CBT alone can make to people who are experiencing the symptoms of psychosis but are not taking medication (The Action Trial – 'Assessment of cognitive therapy instead of neuroleptics').

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Who are the therapists?

Cognitive behaviour therapists are usually mental health professionals who have had special training. They may be clinical psychologists, but they may also be mental health nurses, graduate mental health worker or other type of professional. Sometimes, therapists are trained to follow manuals that have been developed in research studies and are designed for specific problems.

One recently published research study illustrated the success of training mental health workers from different professional backgrounds to deliver cognitive behaviour therapy for psychosis. The research team trained nurses, occupational therapists and social workers as well as clinical and counselling psychologists. (This particular training programme is now run as an accredited Postgraduate Diploma at the Institute of Psychiatry, King's College London.)

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Can everyone who has experienced psychosis access CBT?

The National Institute for Health and Care Excellence (NICE) guideline on schizophrenia says mental health professionals should offer CBT to people who are experiencing both positive and negative symptoms of schizophrenia. People who want therapy should be given CBT on an individual basis for at least 16 planned sessions over a period of six months or more.

The NICE guideline on bipolar disorder says CBT in addition to medication should be considered as part of a long-term treatment package.

However, CBT for psychosis, and CBT for bipolar disorder, is still not available in all parts of the country. Your GP or the mental health team supporting your relative should be able to tell you if it is offered in your area.

An Improving Access to Psychological Therapies (IAPT) service for serious mental illness is currently being developed. This means CBT for psychosis and CBT for bipolar disorder may become more widely available by 2015 through new IAPT services.

There are currently six 'pilot' NHS sites where mental health professionals and researchers are developing and working out the best way to run the new evidence-based 'talking therapy' service for people who have experienced the symptoms of psychosis; for people who have been given a diagnosis of bipolar disorder; and for people who have been given a diagnosis of a personality disorder. The pilot work (that started in November 2012 and is due to end in October 2013) includes working out the most effective way to train therapists. To find out more, visit the IAPT website.