What happens during a CBT for psychosis session?

Dr Emmanuelle Peters: So what will happen during a session of CBT is usually people will already said what the problem list they have, if you like, so will have said the sorts of things they would like help with.

Nothing is imposed in CBT.  So it will depend on the experiences and problems that the person has come up with but you may, for instance, if you are working on an experience like hearing voices when no-one is around, hearing distressing voices, then you might want to start thinking with the person in terms of not just when the voice happens and where it happens, but also a little bit about what beliefs they have about the voices.

Most people who hear voices, for instance, will have some kind of personification, so they will have some idea about who the voice might be – be that spirits or the voice of a previous abuser, or djinns, or some kind of identity. They’ll also have some idea about how powerful they might be, what they can do to them and other people, so you’ll be working on trying to elicit the kind of beliefs that the person has about those, and then trying to work with the person to make them see that potentially these are beliefs rather than facts, and that’s a core part of CBT of course – which is that the way in which people see things may not be the way they are, and that recognising that and then perhaps thinking of other ways, more helpful ways, of thinking about their voices, their identity, their power, would be less distressing and would be more helpful.

Or if you are perhaps working on somebody’s distressing belief, like believing that people mean them harm, or that people are out to get them in some way, then you might be looking through day-to-day examples of what has been happening.  So you may say, ‘OK so you came here on the bus today, there was someone staring at you, there was something about the way they moved which gave you a message that they were going to target you, that they could read your mind in some way – now let’s just look at that again and let’s just think about the thought processes that happened to make you come to that conclusion.’

And you might very gently be trying to find an alternative explanation of what might have been going on, you might be thinking about the way in which the person’s thinking processes work, how they are jumping to conclusions about things. Are they being very hyper-vigilant, looking out for signs of danger all the time, which is making them notice absolutely everything around them? And you would also, near the end of the session, then be setting a homework, you’d be trying to say, ‘Well let’s test things out. You know, we don’t know what’s going on out there so let’s try to be like a mini-scientist and see, can we just test out what that person might have … whether they were out to get you or not.’ 

For instance, the person might have got off the bus because they were so convinced they were about to be attacked.  ‘What about next time, if you try to force yourself to stay on the bus? Perhaps distract yourself so that you are not giving them eye contact all the time and not noticing so much – let’s just see what happens.’  And you set up a behavioural experiment.  And it’s crucial to the therapy process, so that people actually learn for themselves. 

It’s not about taking somebody else’s word for it, it’s not about me saying: ‘I’m the therapist, I know better, you should do what I say.’ It’s very much: ‘Let’s just try and look at this together and you look out for yourself and you see for yourself’ and that’s how things change – not by telling people what’s right, as opposed to what’s wrong.