An evaluation of CBT for psychosis using a clinical case study format.
Subject: Cognitive therapy (Usage)
Cognitive therapy (Health aspects)
Psychoses (Care and treatment)
Psychoses (Patient outcomes)
Author: Hutcheon, Donald
Pub Date: 09/22/2009
Publication: Name: Annals of the American Psychotherapy Association Publisher: American Psychotherapy Association Audience: Academic; Professional Format: Magazine/Journal Subject: Psychology and mental health Copyright: COPYRIGHT 2009 American Psychotherapy Association ISSN: 1535-4075
Issue: Date: Fall, 2009 Source Volume: 12 Source Issue: 3
Topic: Canadian Subject Form: Cognitive-behavioural therapy; Cognitive-behavioural therapy
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 208639910

A clinical case format was conducted by the author to assess the efficacy of Cognitive Behavioral Therapy and adjunct coping skills with a female diagnosed with a psychotic illness. The treatment outcome after fifteen sessions was positive as assessed by a reduction in presenting psychotic symptoms and an increase in the client's self-awareness and confidence.


Current research suggests that the effect of rehabilitation on the myriad of cognitive difficulties in schizophrenia are substantial. Rehabilitation strategies/interventions that combine interpersonal skills training and cognitive methods appear to offer the most generalized results. Clinicians tend to teach Cognitive Behavioral Therapy (CBT) coping strategies to psychotic outpatients in an effort to increase client 'quality of life'--the non-specific improvement of life satisfaction that results from reduction of auditory and visual hallucinations, delusions, and disorganized thought patterns. Learning effective CBT coping strategies to challenge and restructure impaired cognition yields, at the least, increased frequency of patient statements about 'quality of life' and, at the most, generalization of these coping techniques to be utilized on a day-to-day basis. Unfortunately, measuring quantifiable change in personality has been a difficulty with this clientele as attention, concentration, and processing deficiencies have rendered most testing impractical (e.g., MMPI; PAI; MCMI).

Cognitive remediation paradigms (e.g., Corrigan, Schade, & Liberman 1992; Kingdon & Turkington, 1994) have suggested an attempt to moderate patients' levels of physiological arousal. Relaxation strategies that reduce the outpatients' state of arousal may have positive cognitive effects. It has been suggested (Corrigan et al., 1992) that understanding the various forms of cognitive impairment and rehabilitation in schizophrenia requires a superordinate framework model such as the 'Vulnerability-Stress-Model' (Perris, 1989). More specifically, that a Vulnerability-Stress Model may enhance cognitive models of rehabilitation over the course of treatment. For example, relaxation strategies that reduce anxiety for hyper-aroused patients and intervention strategies that stimulate hypo-aroused patients may have positive cognitive effects. When the psychotic outpatient is intensely anxious and available processing capacity is diminished, dysfunction is caused in information processing.

It has also been suggested that, as cognitive remediation strategies continue to develop, clinical investigators need to specify the strength of treatment efficacy. During the past twenty years, the development and use of cognitive behavioral techniques have been adapted for schizophrenic patients (Kingdon & Turkington, 1994). The following study outlines a treatment paradigm of coping strategies taught and successfully utilized by a schizophrenic outpatient to remediate thought disorder, delusions, and auditory and visual hallucinations.

Purpose of Study

"Linda," a 25-year-old female outpatient of Korean origin, was referred to the writer to commence 'treatment of symptoms' as requested by her parents. A standard psychiatric history, mental status examination, and structured clinical interview were used to elicit significant life events as perceived by the client and to obtain a working differential diagnosis (i.e., undifferentiated schizophrenia; rule out schizoaffective disorder). Throughout the interview, Linda described presenting symptoms that had occurred on a daily to weekly basis including auditory and visual hallucinations, delusions of reference, magical thinking, and periodic depression, all of which had been prevalent during the past four years of her life.

Background Information

At age twenty, an initial psychotic episode occurred during Linda's first year at junior college with the aforementioned array of symptoms. This had caused Linda great emotional pain and anguish, loss of friendships, and loss of capacity to finish her post--secondary schooling. She remained at home and watched as her former friends continued on with successful achievements while she "stayed at home to play her violin, paint, and watch TV." The writer established that an overall treatment goal aimed to reduce psychotic symptoms by utilizing a gradually accumulated array of coping strategies and to operate from a cognitive behavioral treatment perspective (i.e., cognitive restructuring).

It was also stated to the family that the treatment emphasis would be in the 'here and now' and would initially require weekly, 90-minute sessions to develop a therapeutic alliance and successfully teach CBT strategies. It was emphasized that the therapeutic alliance developed during the course of treatment was of utmost importance. More specifically, throughout the treatment period, a close relationship would be established not only betweent the therapist and client, but a consensual understanding of the process developed between the client, therapist, significant others, and, if required, the other mental health professionals (e.g., family physician, psychiatrist) previously involved in treating Linda. The writer further reinforced the importance of the overall treatment goal: the improvement of Linda's subjective 'quality of life' via the assimilation of coping strategies to process and reduce her chaotic inner experiences.

Treatment Concepts

One concept of major importance when treating outpatients diagnosed with psychosis is 'expressed emotion' (EE) (Dailey & Moss, 2002, p.91). EE is evaluated by counting the number of critical statements, hostility, and emotionally-loaded behavior within the family unit. A high EE attitude in professionals and the outpatient's support network correlates with a worse treatment outcome (Merlo, Perris, & Brenner, 2002). In the post-acute phase of the illness, reactions to schizophrenic outpatients are often characterized by either extreme criticism (imputing a negative valence) or over-involvement (imputing incapacity). In regards to this, Podvoll (1990) considered a healthy therapeutic atmosphere as possessing a positive relationship with the patient, characterized by empathy, acceptance, and avoidance of unnecessary power over the individual.

The basic premise of cognitive therapy suggests that cognition is responsible for behavior and emotions (Beck, 1976; Ellis, 1979); ostensibly the mind affects emotional interpretation of events. Negative cognitions are influenced more by thought patterns based on a systematic mistake in thinking and less by actual environmental conditions. Hence, therapists utilizing cognitive behavioral therapy believe that an effective treatment paradigm can be achieved only by recognizing and altering basic cognitions about unrealistic schemata and mistaken thinking patterns.

Within the cognitive behavioral paradigm of treatment strategies, various authors have developed therapeutic approaches that emphasize the importance of the interaction between cognitions, emotions, and behavior (e.g., Beck, 1976; D'Zurilla & Goldfried, 1971; Ellis, 1979; Meichenbaum, 1977). EE has been a major predictor for the development and continuation of psychotic behavior (Brown, Monck, Carstairs, & Wing, 1962; Vaughn & Leff, 1976). In this regard, the atmosphere of the family system from which a schizophrenic outpatient resides is paramount for further development of the illness. The risk of relapse is much higher if the outpatient resides in a family with high EE and is compounded by poor medication compliance.

Teaching the family members and schizophrenic outpatient the fundamentals of progressive deep muscle relaxation techniques (Bernstein, Berkovac, 1973)--thought-stopping, counting and visualizing numbers, and diaphragmatic breathing exercises--are all important adjuncts to basic cognitive behavior therapy interventions that reduce unhealthy levels of EE.

A treatment plan was discussed with Linda and her family. The plan included 1) Treatment interventions that would be built upon and expanded; 2) Discussing the nature and subjective understanding of the schizophrenic illness during early sessions to address any/all misperceptions about the treatment challenges; 3) Cognitive training exercises for psychosis regarding coping strategies to counteract the negative effect of auditory and visual hallucinations and delusions; 4) Cognitive restructuring; 5) Self-regulation strategies; 6) Imagination behavior exercises including relaxation training; and lastly, 7) Working with the parents after the treatment session had concluded with their daughter for that particular week.

The interventions were introduced in stages, which were expanded, rehearsed, and reviewed on an ongoing basis. Brenner, Kraemer, Hermanutz, and Hodel (1990) have suggested teaching and applying cognitive methods before behavioral interventions. The rationale being that if cognitive performance is improved through specific cognitive training, individuals would be able to be taught progressively more complex therapy and rehabilitation techniques even if the cognitive skills deteriorate.

Within the therapeutic plan devised for Linda, a flexible and personalized manner of treatment was introduced. The method of training in the respective treatment domains depended on Linda's readiness and mental condition for that particular week of therapy and included, as one criterion, a review of the completed homework assignments.

The frequency of individual sessions was mutually decided upon between the writer, Linda, and her parents. Weekly sessions for an initial period often weeks were conducted with the central feature of the treatment being the actual therapy techniques being assimilated. This took the longest period of time in the overall treatment paradigm. Five additional treatment sessions were mutually decided upon based on Linda's progress during the first ten sessions. The following section illustrates each treatment phase and the outcomes that occurred.

Treatment Process

Phase One: Assessment & Treatment Overview

Session 1 (December 9, 2007)

Linda arrived punctually with her parents, at which time a history was completed, including a Mental Status Examination and Structured Clinical Interview. Her daily medication included 3 mg of respiradone, .25 mg of alprazolam, and 12.5 mg of fluoxetine; the fluoxetine had recently (within the past two days) been reduced by Linda's father who, in consultation with the family doctor, felt 25 mg of fluoxetine was too high a dosage level. Linda had been recently (within the past six months) diagnosed with schizoaffective disorder--depressed subtype by a hospital psychiatrist. Previous hospital diagnoses in recent years had included undifferentiated schizophrenia.

The first psychotic symptoms occurred when Linda was 20 years of age and consisted of auditory and visual hallucinations with a frequency averaging twice per day (command hallucinations). The visual hallucinations included a shampoo bottle 'attacking' Linda, and visual images of a couple having sex. Persecutory delusions included a scary animal trying to harm Linda, pilots in a plane overhead landing nearby to enter Linda's home to assault her, and passing cars attempting to hit the family car while Linda was a passenger.

During the history-taking, the father informed the writer that his daughter had been a 'bad asthmatic' since age six, at which time she was given steroid injections in a Korean hospital after an attack, which helped to reduce future asthmatic problems. By age 13, the asthmatic problems were gone.

The father stated that, in grade 10 (age 14), his daughter, who had recently moved to Canada with the family, had a stressful time socially and academically. She became friendless and isolated and found the English language hard to master. She had two younger twin brothers (age 7) who, according to the father, assimilated quickly and comfortably into the Canadian culture and lifestyle.

Between ages 18-25, the father stated that his daughter began having depressive episodes, and at age 20 experienced her first episode of psychotic symptoms, which frightened her. The father further stated that Linda was/is very artistic and musically inclined and was accepted into a well-known local (i.e., Emily Carr) art school and also the prestigious and highly selective Ontario Art Institute. She attended the local art school for one semester in her early twenties but dropped out, unable to cope with the stress of socializing and the time demands to submit assignments.

When the writer interviewed Linda, her language skills indicated a paucity of age-appropriate vocabulary, grammar, and extended latency in responding to questions. The writer assessed her literacy at a 'general working knowledge' of the English language. This information negated utilizing standardized paper and pencil self-administered psychology tests, as the results would have been invalid. Linda stated she was "confused half the day about what to believe because of visual and auditory hallucinations." She also made delusional statements such as "A little crow is sitting in a tree sending messages to me. What should I do, Doctor?" Her affect and voice modulation was flat, and she repeatedly asked the writer "How do I know what is real and not real?" She explained that she passed time by practicing her violin (which she had played since age seven) daily and drawing pictures "about my feelings and what I'm seeing."

The writer ended the interview by answering the parents' questions and providing an opinion regarding the previous differential diagnosis of Linda's illness (i.e., undifferentiated schizophrenia rather than schizoaffective disorder). A brief discussion ensued about the nature of treatment application, which included Cognitive Behavioral Therapy for Psychosis and further adjunct coping strategies to use to reduce general anxiety and provide a working paradigm to utilize against hallucinations and delusional behavior. The writer discussed the use of weekly 'homework' assignments and the need for the parents to establish a low 'EE' environment that was not stress-provoking. This also included the parents meeting with the writer for a period of 15 minutes immediately following the weekly therapy sessions with Linda in order to debrief the session and provide a stratagem, if required, that augmented the treatment techniques taught to their daughter. The first assignment was discussed with both Linda and her parents present; it requested Linda draw a pictue that reflected her feelings.

Phase Two: Developing Therapeutic Alliance & Treatment Adherence

Session 2 (December 15, 2007)

Linda arrived 15 minutes late because her parents had lost the directions. Linda brought a list of 35 questions in a 'homework book' pertaining to the nature/quality of her illness and its symptoms, which we discussed at length. Her father, in consultation with the family doctor, discontinued the anxiolytic medication, which he stated "had had no real effect on Linda's emotional state." Linda stated that she had begun the picture as requested in the previous session, but she had not yet completed it.

With the remaining time, the writer taught Linda the basics of cognitive behavior therapy for psychosis, which she assimilated well. Subsequently, Linda was also taught progressive deep muscle relaxation techniques (16 major muscle groups), developed by Bernstein and Borkovac (1973), and another homework assignment was introduced: to complete the relaxation techniques formally three times per day. The writer discussed Linda's array of delusions, which included the TV, telephone, and other inanimate objects (e.g., chair) telling her to complete various activities, some of which were socially unacceptable. Other delusions included her belief that closing the top of a water bottle would disallow her ability to breathe. At this point, the writer had Linda test the delusion by tightening the water bottle and allowing her to see that she could still breathe. The writer encouraged Linda to 'challenge' other delusions and demonstrated role-playing a 'challenge' for an obvious delusion: the television talking to her directly. Linda understood the intention of the role-playing exercise as the initial stage in learning to confront delusional messages, with the knowledge that professional support was available via telephone if urgently required.

Linda's parents arrived to pick her up and were given 15 minutes of feedback regarding the content of this particular session, strategies learned and their rationale, and the parental role at home to ensure their daughter felt safe and able to complete her treatment tasks.

Session 3 (December 22, 2007)

Linda arrived on time and stated that the medication made her drowsy. She was currently receiving fluoxetine 12.5 mg; respiradone 3 mg; and was no longer taking the anxiolytic, alprazolam. Linda stated that she experienced visual hallucinations during the past week, 30% of which she firmly believed were "real" and 70% she thought were "fake." We reviewed the previous session's homework assignment of progressive deep muscle relaxation. Regarding her tendency to stay at home, the writer suggested a structured daily activity plan that included walking independently to her choice of a number of locations (i.e., shopping mall, theater, store, park, community center).

The writer introduced systematic desensitization (exposure therapy) regarding Linda's fears of walking to and entering a mall alone. The writer developed a 'fear hierarchy' of mental images (e.g., walking to the mall, entering the mall, buying clothes in a mall store, interacting with store clerks, leaving the mall). The hierarchy was presented two to three times, and had Linda use progressive deep muscle relaxation paired with each level of the fear hierarchy in an attempt to reduce a fear. The technique worked well and was expected to be utilized each day, prior to Linda taking the walks. The coping strategies of thought-stopping when stressed by an event; counting while visualizing numbers from 1-8; relaxing two to three muscle groups; and completing diaphragmatic breathing (i.e., counting up from 1-4, pausing for a count of two, and then counting down from 4-1) were also introduced and practiced during the session.

Linda's parents arrived towards the end of the session and the writer debriefed them on their daughter's homework assignment for the following week (i.e., completing the picture previously assigned; relaxation techniques, and systematic desensitization).

Session Four (December 28, 2007)

Linda arrived on time and discussed the previous week. Visual hallucinations had occurred: "Fifty percent were real and fifty percent fake." More specifically, the visual hallucinations consisted of "a person changing to a phone or a car and then talking to me." Linda stated that, when attempting to touch a telephone, the phone responded, "Don't touch me." She also stated that the garbage can in the kitchen would occasionally "disappear." Linda was asked about her level of anxiety during the past week: "It's down approximately 20% and some days down 40-50%." She also stated that when she became angry she would play her violin, watch TV, and eat.

The writer asked Linda about the local Health Care Outreach Team contacting her to join an outpatient group; she replied that they hadn't phoned yet. The discussion then focused on the homework assignment given the previous week. Linda kept a record of the completed relaxation exercises formally three times per day as arranged, and relaxing two to three muscle groups on a case-by-case basis regarding stressful events. This working paradigm served two rationales; the first to increase her stress threshold, the second to match a stressor with a relaxed state, thus reducing the severity of 'expressed emotion.' Linda also discussed using systematic desensitization to reduce her anxiety over walking alone to the local mall. She stated, "It didn't work well. The results were mixed, so I stopped, but the mall fear was reduced."

The writer reviewed the counting sequence, visualizing numbers 1-8 as an additional coping strategy to interfere with emotional rumination. Linda's responses indicated that reduced anxiety and anger correlated with a reduction in both auditory and visual hallucinations.

Linda asked if one of her goals for the next week could be to have her hair cut and styled. In addition, she stated she would actively attempt to challenge the day-to-day delusions more aggressively. Toward the latter portion of the session, the writer developed a new fear hierarchy utilizing systematic desensitization for going to/attending church and theater. Linda's goals for the next treatment session (Jan 5, 2008) included:

1. Utilizing systematic desensitization on a daily basis for church and theater

2. Progressive deep muscle relaxation (16 muscle groups) three times per day

3. Utilizing CBT for psychosis and coping strategies as needed throughout the day

4. Hair cut/styled

5. Contact the Health Care Outreach Team regarding attending weekly outpatient groups.

Linda's parents arrived toward the end of the session and were debriefed concerning Linda's homework assignment and discussion of any questions pertaining to the previous week. Their behavior was somewhat dismissive of the hair cut/style, stating their daughter was being too whimsical and made frequent requests to change her appearance. The writer asked if Linda could be allowed this particular time to have her hair cut and styled, to which they agreed.

Phase Three: Habituation of CBT Techniques and Coping Strategies

Session 5 (January 5, 2008)

Linda arrived on time and debriefed the writer on the prior week's activities and homework assignments. She completed the relaxation training experience (16 muscle groups) three times per day and systematic desensitization (i.e., shopping mall) several times prior to in vivo (actual) training, going to and from the mall. She had her hair cut/shaped with an enhanced look from the previous straight, dull appearance and brought a completed picture, which had been her homework assignment from the first week. The writer suggested another goal to commence this week: a daily exercise program both at home (home gym available) and a choice of outdoor strolls (i.e., to and from the mall, park, theater, church).

The writer discussed Linda's mood during the past week. She stated the depression had diminished from occasionally "feeling down" to being "improved--I'm a lot happier." Linda stated the Health Care Outreach Team had still not contacted her regarding attending a weekly outpatient group. In addition, Linda stated that her sleep was better than previous weeks. She was getting up at 9:00 a.m. as opposed to sleeping in until 10:30 a.m., as was her usual habit. Linda stated her appetite was excellent; she was eating three meals per day, both Korean and Canadian dishes. She also stated that she was not comfortable traveling alone and felt "less scared" when her mother traveled with her.

The writer queried delusions and hallucinations during the past week. Linda stated she had experienced one delusional experience, where she thought, "The kitchen garburator will eat me." She was asked to challenge the delusion by examining how the garburator would be large enough to eat her. Linda replied, "So it's fake," and was praised by the writer. Visual hallucinations had also occurred, including "a car and a phone that look like a person." Linda stated the auditory hallucinations had markedly reduced in frequency and included statements such as "Who are you?", "Hello!", and "I don't like your hair style!" Linda requested assurance by stating, "So I challenge these as well?" She was encouraged to do so.

Lastly, the ongoing fears of the mall, church, and theater were discussed and the writer reintroduced the systematic desensitization fear hierarchy regarding attending theater followed by another fear hierarchy, traveling to a swimming pool. These were completed 'in vitro' during the session with a homework assignment to complete both the following week 'in vivo.'

Linda stated she was more organized during the past week, having purchased a planner to organize her daily activities. Her personal goal was to teach art in Sunday school when she felt more confident. The writer suggested choosing between four to five walking options (e.g., mall, church, theater, park) on a daily basis. Linda's parents arrived and were debriefed on her progress during the past week. They mentioned that Linda was becoming more confident, challenging the hallucinations and delusions, and getting better at determining "what is real and what is fake."

Session Six (January 12, 2008)

Session six entailed reviewing the past week with Linda. She traveled to the mall alone twice and will attempt to travel to the church and theater this week. Linda stated she was still having auditory hallucinations: "What I think is what I hear." She felt the phone was talking to her and "can read my mind!" In conjunction, visual hallucinations included the phone that "looked like a person." To counteract the auditory and visual hallucinations, Linda said she listened to music to "divert the thoughts and to replace the phone messages with something else that was nice." Linda stated the recent change in medication helped her be less groggy and think more clearly. She was contacted by the Community Health Team about an outpatient weekly group for schizophrenics, which she decided to attend once to see if she liked it.

The treatment objectives for this session included a review of the following strategies: CBT--Psychosis; progressive deep muscle relaxation (16 muscle groups); thought-stopping; counting (visualizing numbers 1-8); diaphragmatic breathing; and systematic desensitization (i.e., dog, sleeping alone when frightened). The goals for the following session included: challenging the auditory and visual hallucinations and delusional beliefs (e.g., dog talking to her); bringing her violin to the session and playing a rehearsed song; and walking alone once per day to either the mall, park, a friend's home, or church.

Linda's parents arrived towards the latter portion of the session and were debriefed regarding the homework assignments and reinforced for carefully gauging their interactions with their daughter visa vis reduced expressed emotion (i.e., EE).

Session Seven (January 17, 2008)

Linda arrived on time and discussed the past week's homework assignments. She was able to successfully walk to the mall and the theater alone after completing progressive deep muscle relaxation exercises to calm her anxiety. She also discussed a two-year delusion about a Korean man she met in church: "Mr. Lee, who resembles a car I saw driving by." Linda was able to assert that the car (i.e., Mr. Lee) was a delusion and "was fake" and was able to challenge the delusion by utilizing the coping strategies learned in previous sessions. She also successfully diverted her attention from the delusion by watching TV Overall, Linda felt the past week's delusions were "Eighty percent about 'man stuff' and 20% about other issues." She further stated that she felt "a reduction in safety when thinking about sex" and tends to turn on the Korean broadcasting network to divert her attention.


Lastly, Linda stated she had a habit of sleeping in her parents' bedroom at night when she has nightmares or hallucinations. On a positive note, the treatment techniques had helped to reduce her anxiety during periods of distress, allowing her to sleep alone once during the past week when she was having a nightmare. Previously, this would not have been feasible.

Linda's parents arrived shortly thereafter, at which time the writer encouraged them not to allow her to sleep in their room for comfort/support, but conversely to remain in her bedroom and complete the coping strategies independently to reduce her fears. They agreed to follow the plan.

Session Eight (January 28, 2008)

Linda arrived on time and discussed the past week's events. She felt much more comfortable walking independently to the mall, park, and theater. She mentioned a marked reduction in both visual and auditory hallucinations due, in her opinion, to an increased comfort in utilizing the CBT-psychosis techniques and coping strategies. Linda asked if she would ever be 100% free of the psychotic symptoms in her lifetime. The writer responded with "probably not," but stated that continued use of the coping strategies and understanding the cause of the symptoms would reduce her anxiety by providing greater insight and a choice of strategies to reduce the discomfort the symptoms precipitate. Linda also discussed the reduction in frequency of the "Mr. Lee" delusion, assessing this delusion as "fake" with no further need to "check the phonebook" regarding his name and address.


At this point, the writer discussed Linda's structured daily activities for the past week. They included English Bible study (1 hour); music (1 hour); reading English and Korean novels; drawing artwork; and walking independently in the neighborhood to prearranged locations, which included the mall, park, or theater. She received information about the weekly outpatient group, commencing February 12th at the local hospital. During the past week, she had less stressful symptoms pertaining to sex, which she attributed to her prayer and spiritual strength. In conjunction, we discussed the "Mr. Lee" delusion at length and the writer encouraged Linda to use the CBT techniques of restructuring, stress management vis a vis decatastrophization, analysis of evidence, and refutation of the delusional belief via alternate explanations. Linda stated that she was much more comfortable using the aforementioned techniques to challenge the delusion and currently was successful "Ninety percent of the time."

Linda's parents arrived shortly thereafter and were debriefed on Linda's current status in therapy. Further discussion ensued regarding future goals and treatment stratagem for the remainder of the prearranged treatment sessions (up to 15 were suggested at the initial session by the writer, and were agreed upon by Linda and her parents). The writer also suggested the parents reduce their tendency to "baby" their daughter, thus introducing new, more age-appropriate strategies of coping with her psychotic behavior. They agreed to focus on changing their parental style by adopting a more 'adult to adult' as opposed to 'parent to child' interaction with Linda.

Session Nine (February 3, 2008)

Linda arrived on time and stated she had been "depressed the last week." She felt "people had been nasty and giving me weird signals." The writer suggested this was called 'thought insertion' and was a symptom of her illness and should be challenged. We reviewed Linda's structured daily activities, which included walking to a specific predetermined location, using the treadmill in her basement for 15 minutes, and utilizing the weightlifting equipment to help reduce excess body fat by approximately 5 pounds. Linda mentioned that while cutting vegetables in the kitchen, she imagined "the knife was cutting my brain," which she challenged by using the aforementioned CBT techniques (see session eight), causing a marked reduction in her anxiety.

The writer and Linda spent time discussing the nature of psychotic symptoms (i.e., thought disorder, auditory and visual hallucinations, delusions) and she appeared more comfortable accepting the nature of their presenting features, and in turn, utilizing the coping strategies learned and practiced during the past nine weeks.

Subsequently, upon her parents' arrival, we discussed the next week's homework assignment and debriefed the parents' attempts to modify their style of interaction with their daughter. The maturity of Linda's verbal response describing her parents' adjustment in behavior toward her appeared to please them.

Phase Four: Refining CBT Techniques and Supplemental Coping Strategies

Session Ten (February 10, 2008)

Linda attended the session punctually, as usual, and debriefed the writer about the prior week's activities and homework assignment. Linda was asked to improvise a sketch during the session using a 'free association' approach where no bounds were imposed. The result was a picture with interwoven lines, circles, swirls, cross-hatched squares, and a half moon surrounded by curved lines. Linda said she was able to attend and concentrate comfortably during the exercise without interference from hallucinations or delusions. Linda also completed a 'self portrait' in pencil, which was realistic in appearance and generally resembled her facial features. Of note was the focal point of the picture--the eyes, which were drawn with a piercing, bold expression.

During the past week, Linda stated she had experienced the delusion that "a car was trying to eat me" but was able to challenge the delusion's content as being unrealistic utilizing CBT techniques. She further stated that she was not being overwhelmed by fears that the delusions would defeat her. She kept busy by structuring her day with the following activities: reading the Korean Bible and a Korean book; drawing a picture using pastels; cooking Korean food and watching Korean TV; and daily exercise in the home; and going for walks to predetermined destinations. She also stayed at a friend's house for two days and watched Korean TV and listening to some Bible scriptures. Linda discussed her goals for next week: joining the Community Mental Health Team's weekly group meeting, drawing with water colors and oil paints, watching TV, reading, and daily exercise. During the current session, the writer taught a condensed form of the progressive deep muscle relaxation exercise of 'chunking' 16 muscle groups down to seven, which Linda learned easily.

Linda's parents arrived approximately fifteen minutes prior to the end of the session and were debriefed about Linda's progress in therapy using CBT techniques supplemented with coping strategies learned in previous sessions. They remarked that Linda was experiencing "less fractured days," referring to a reduction in hallucinations and delusions. She was also utilizing the treatment strategies learned in the sessions with greater effectiveness and spontaneity.

At this time, Linda requested a reduction in frequency of the sessions from weekly to monthly, to which the writer countered by stating, "Lets keep it at weekly sessions for the time being." Linda and her parents accepted.

Session Eleven (February 17, 2008)

Linda arrived on time and stated, "It was a bad week; I was frightened, scared, and worried." She went on to discuss her disappointment with the Community Outreach Group, which she felt was not helpful or supportive: "The people there frightened me." Her delusions had returned, including one that she described as a "building that gave me a weird signal." She further described paranoid delusions of her father stating to her mother, "We should kill our daughter."

Linda stated she felt overwhelmed with sadness and loneliness when this had happened. The writer re-established the need to utilize the CBT techniques when the delusions and hallucinations occur. Linda stated she had tried but was "overwhelmed with the content and fear of my parents potentially harming me." The writer asked Linda to complete another drawing using the 'free association' approach; she did and named it 'Jesus drawn by Linda.' The sketch was completed in blue crayon and replicated the bust portrayals of Jesus. A noticeable attribute was a sad expression accentuated by the development of the eyes and shape of the nose and large lips, which made the picture appear to be feminine.

Linda subsequently debriefed her activities during the past week, which did not include the exercise program twice per day as developed during previous sessions. Her parents arrived to pick her up and confirmed that the past week had been a particularly difficult one for Linda. The writer provided an 'empathic ear' during the debriefing and reassured them that their daughter's improvement during the past six to eight weeks was genuine and this past week's setback should not be overemphasized.

Session Twelve (February 23, 2008)

Linda arrived on time and debriefed the writer about the past week's activities. She stated the delusions were much less frightening as she was becoming more comfortable challenging them with CBT coping strategies. Linda made further reference regarding the nature of the intensity of her illness being "Sixty percent now and before treatment it was ninety percent." She was happy as she was able to walk outside every day, shop, and have a hairstyle. She stated she did not do ally art or music during the past week and digressed in conversation to discuss one of her frequent delusions of "cars looking like people." Linda described the delusion as being "fake and I try to ignore it because it's part of my illness. When I do this I don't overreact."

The writer completed an in vivo exercise this session by asking Linda to join him in a twenty-minute driving tour around the neighborhood. This exercise allowed the writer to observe Linda's ability to challenge her anxiety while driving as a passenger and to utilize the CBT coping strategies learned, practiced, and refined throughout the previous eleven treatment sessions. Linda agreed to accompany the writer and throughout the driving exercise was actively delusional: "The cars look like people." She was able to actively challenge the delusions with infrequent prompts from the writer and at the end of the twenty minutes stated, "The techniques worked, I know they (i.e., the delusions) are part of my illness and I am less afraid now." Subsequently, back in the office she discussed her fear of people sitting in church on Sundays, specifically Mr. Lee. Linda further disclosed that, "Mr. Lee is evil when he talks to me." The writer encouraged Linda to utilize the CBT techniques when this occurred and she confided that during the past several weeks "the disordered thoughts I was having are gone."

The writer ended the session with teaching all additional "chunked" version of the Progressive Deep Muscle Relaxation technique from seven to four muscle groups, which increases the efficiency of achieving a state of physiological relaxation. The writer also encouraged Linda to continue her daily exercise program, which included using the treadmill and flee weights in her home in addition to daily walks to a predetermined location. She ended the session by drawing a picture that reflected her state of mind: "feelings make me settled." The drawing included twenty-eight lines designed in a wavy motion to resemble a beach with circles interspersed (on the beach). At the far right hand corner of the picture was a small circular array of lines, which the writer associated with either the sun or bushes.

Linda's parents arrived at this time and the writer debriefed them regarding the in vivo exercise, her progress in utilizing the CBT exercises, and reduction in fear regarding the car delusions. They were also surprised that Linda stated her thought disorder from her point of view was abated. The writer requested that Linda be allowed to complete a projective test (Thematic Apperception Test) in future sessions to allow greater examination of her personality strengths and weaknesses. Linda agreed with this recommendation, and her parents supported this decision.

Session Thirteen (March 2, 2008)

Linda arrived promptly for the session and debriefed the writer about the previous week's activities. She was able to challenge auditory hallucinations more readily: "The TV and car talked to me but the voices went away naturally." Linda complained of morbid dreams during which she was "killed by a knife" and occasionally she had a delusion about "Mr. Lee."

Overall, Linda stated her fear from the dreams was now "thirty to fifty percent less fear when I wake up than before." Linda completed artwork this past week and ordered pastels for future drawing exercises; she did not listen to music but studied the Korean bible. Linda also stated she had "less fear the past week than previous weeks" and decided her goals for next week should include more extensive sketching and artwork; talking with her grandmother who lives in Korea and to her twin brothers at the University in Saskatchewan; continuing to utilize CBT techniques to challenge the delusions and hallucinations; and exercising in the home gym fifteen minutes twice per day, complemented by walking approximately forty minutes per day to a predetermined location.

Linda's final statement entailed fears about her parents: "One-third of the time I have a feeling that my parents have changed (are changing) to evil." When asked to explain the statement, she did not wish further dialogue. Shortly thereafter her parents arrived and stated Linda's behavior during the past week had "returned to before," indicating a reduced level of psychotic symptoms. The writer observed they were both pleased with Linda's active utilization of the CBT techniques and her comfort level and spontaneity in using the various coping strategies. Linda requested once again to extend her sessions to once per month and the writer countered with, "How about bi-weekly, which means every two weeks?" Linda looked pleased and accepted this compromise. Her parents also agreed with the new arrangement and stated they would call the writer if Linda's behavior appeared to decompensate.

Session Fourteen (March 16, 2008)

Linda arrived punctually and stated it had been a "hard two weeks"; she had been physically sick with the flu and a cold, which caused some depression. Linda stated she had experienced "fewer auditory hallucinations ... one week had been good, the other hard." She also emphasized that visual hallucinations were much less infrequent during the past week: "A car looked like a person and it stepped on me." She was able to diffuse the delusion by using the CBT techniques, which gave her "a sense of control." Linda also stated that her "depressed feelings were reduced when she exercised regularly," which she was able to achieve periodically when her cold and flu subsided.

Linda utilized her spare time during her illness by sketching and studying the bible, occasionally meeting with friends, and talking with her grandmother in Korea and her brothers at the university. She disclosed that her "happiness has increased bit by bit and I feel better than last time (i.e., session)." Linda stated she was still receiving morbid dreams with aggressive themes--four during the past two weeks. "Someone kills me with scissors, a knife, or during a fight." Subsequently, she discussed the positive effect that attending a Korean church had on her quality of life, which had been facilitated by learning, practicing, and actively utilizing the CBT techniques. "I am learning to make and keep friends, who in turn help each other, saying hello to each other and being there (each Sunday)."

Linda completed the projective assessment (i.e., TAT) for the second time. This session required more expansive interpretations of the various pictures shown her. Afterwards, Linda discussed her goals for the next and final treatment session: drawing a nice pastel picture; continuing to utilize the CBT techniques to challenge the psychotic symptoms; using the other coping strategies to increase her stress threshold; exercising in the home gym twice per day and walking each day for extended periods of time to a prearranged location.

Lastly, Linda stated she felt "happier and more relaxed and able to concentrate better" during the past week. Linda's parents arrived shortly thereafter and confirmed Linda's description of her behavior. They commented on improvements in her appearance, her ability to challenge with greater comfort the psychotic symptoms, and her reduced anxiety and increased willingness to attempt both structured/predetermined and novel activities throughout the day.

Session Fifteen (April 6, 2008)

Linda arrived punctually for her last session. She debriefed the writer about her last week and described using the CBT techniques for psychotic symptoms successfully. She had received the pastels ordered the previous month and was very excited. The 48 color range allowed her to design more colorful pictures. During the past week she drew three pictures, which she showed the writer. Each picture was 'expertly crafted,' one showing a brilliant array of colors representing a rainbow in the background of the picture.

Linda stated she had experienced "bad dreams of scary ghosts coming" and further commented with pride that she was able to stay in her room and did not need to go to her parents' bedroom. She stated she had continued her daily exercise regime in the home gym and walking activity in the neighborhood. Of note was Linda's disclosure that she was "only hearing voices 10-15% of the time and I'm seeing things less and less now, only one to two times per week." Linda stated she felt happy and her feeling of being "in control of what I'm doing is getting better and better." The conversation precipitated Linda discussing her past four years since having her first psychotic episode at age twenty: "When I had my symptoms, my friends thought I was a weird person, with voices telling me to harm myself." Her voice trailed off and then Linda began to discuss her goals for the next week, which included sketching pictures using the pastel crayons, playing music, reading a Korean novel, and continuing with her daily exercise regimen.

Linda's parents arrived to pick her up shortly thereafter and discussed the possibility of Linda accompanying them to visit relatives for one month in Korea during the month of May. The writer suggested this was a reasonable idea and would allow Linda the opportunity to practice her CBT techniques in a semi-controlled environment with family members who understand her. It would also provide her with the opportunity for "dignity of risk," albeit prudent risk-taking, under supervised conditions with new activities that are indigenous to the Korean culture. The writer "was as close as the phone" and could be reached at the office or at his home if the need arose. Linda suggested she visit the writer after her vacation to debrief, which was an acceptable arrangement. Her parents were satisfied a valid support system was in place overseas, which would reduce the potential for relapse and allow Linda the opportunity to visit with her relatives and aged grandmother. They were also appreciative of a follow-up phase and post treatment to allow their daughter a network of continued support.


Linda's CBT treatment for pychosis began December 7, 2007, and ended April 6, 2008, after attending 15 sessions. The sessions were originally weekly in frequency then reduced to biweekly after session thirteen. Her parents were closely involved from the treatment outset, including all aspects of the homework assignments and in modifying their parenting style to be reduced in 'expressed emotion.'

Linda's psychotic illness had been diagnosed during the past four years and medication prescribed to ameliorate the presenting symptoms, which caused her a great deal of stress, anxiety, and depression. Her father, in consultation with the family physician, reduced Linda's fluoxetine by half and eventually discontinued her anxiolytic medication (i.e., second week of therapy), which he felt had no effect on changing her behavior.

After completing a psychiatric history and mental status examination which identified Linda's previous differential diagnosis as undifferentiated schizophrenia but not schizoaffective illness, the writer decided on a four phase treatment approach, which included:

Phase One: Assessment & Treatment Overview

* The completion of Linda's Psychiatric History and Mental Status Examination in conjunction with developing a 'working alliance' with Linda's parents that would require weekly post treatment debriefing and homework tasks to complement their daughter's progress and homework assignments.

Phase Two: Developing Therapeutic Alliance & Treatment Adherence

* The development of a strong therapeutic alliance with Linda and her parents. The assimilation and practical application of treatment techniques and strategies to challenge and ameliorate the psychotic symptoms.

* Learning and utilizing cognitive behavior treatment strategies for psychosis: restructuring; stress management via decatastrophization; analysis of evidence; and refutation of the delusional belief via alternate explanations.

* Adjunct coping strategies (progressive deep muscle relaxation); thought stopping; counting (visualizing numbers one to eight); diaphragmatic breathing; systematic desensitization.

Phase Three: Habituating CBT Techniques & Supplemental Coping Strategies

* Cognitive behavior treatment for psychosis: Practicing the techniques consistently on a daily basis; keeping a daily log and developing a 'question-answer' dialogue with the writer vis a vis the various aspects of the treatment paradigm--its strengths and needs as perceived by Linda and her parents.

* Adjunct coping strategies: Practicing, analyzing, and modifying the coping strategies to support and complement the CBT-psychosis treatment paradigm.

Phase Four: Refining CBT Techniques & Supplemental Coping Strategies

* Encouraging and consistently reinforcing Linda's attempts to utilize the aforementioned strategies/techniques to influence a greater degree of confidence and spontaneity by Linda. Increasing the cause-effect association between utilization of strategies that work and reduction of presenting symptoms.

Overall, Linda's feedback and her parents' agreement of her analysis of the treatment efficacy was encouraging throughout the 15 treatment sessions. There was a definite transformation in emotional, physical, and cognitive functioning throughout the four month period of therapy. In general, Linda's psychotic symptoms became less acute and more stabilized over the course of treatment with a reduction in frequency of psychotic behavior by approximately 60 percent. Linda's increased confidence utilizing the CBT techniques and coping strategies also influenced the reduction in fear and overreaction to the delusional symptoms and visual hallucinations. There also appeared to be a 'flattening' of the episodic 'spikes' in psychotic symptoms, which occurred during the first eight to ten sessions (approximately 3 months therapy time). This positive outcome continued to occur throughout the final five treatment sessions, albeit interspersed with infrequent psychotic episodes of intensity (i.e., persecutory delusions about parents wishing to kill Linda). Of note was Linda's statement in the final session: "Only hearing voices 10-15% of the time. I'm seeing things less and less now-only one to two times per week."

A final note entails the parents' comfort in letting Linda join them in visiting her relatives in Korea during the month of May. Linda, her parents, and the writer felt Linda's skill development and comfort level utilizing CBT and the adjunct coping strategies was sufficient to effectively challenge psychotic symptoms. The trip was completed with no mishaps and Linda returned to Canada with enhanced self-esteem, confidence, and reduced frequency of psychotic symptoms.

Cognitive Behavioral Therapy (CBT): A Summary

Cognitive Behavioral Therapy (CBT) is an empirically-supported treatment that focuses on patterns of thinking that are maladaptive, and the beliefs that underlie such thinking. For example, a person who is depressed may have the belief, "I'm worthless," and a person with a phobia may have the belief," I am in danger" While the person in distress likely holds such beliefs with great conviction, with a therapist's help, the individual is encouraged to view such beliefs as hypotheses rather than facts and to test out such beliefs by running experiments. Furthermore, those in distress are encouraged to monitor and log thoughts that pop into their minds (called "automatic thoughts") in order to enable them to determine what patterns of biases in thinking may exist and to develop more adaptive alternatives to their thoughts. People who seek CBT can expect their therapist to be active, problem-focused, and goal-directed.

Over the past 10 years, CBT for schizophrenia has received considerable attention in the United Kingdom. While this treatment continues to be in its infancy in the United States, the results from studies in the United Kingdom have stimulated considerable interest in therapists in the U.S., and more therapists are conducting the treatment now than just a few years ago. In this treatment, patients are encouraged to identify beliefs and their impact and to engage in experiments to test their beliefs. Treatment focuses on thought patterns that cause distress and also on developing more adaptive, realistic interpretations of events. Delusions are treated by developing an understanding of the kind of evidence the person uses to support the belief and encouraging the patient to recognize evidence that may have been overlooked that does not support the belief. Furthermore, the assumed omnipotence of "voices" is tested, and patients are encouraged to utilize various coping mechanisms to test the controllability of auditory hallucinations.

CBT's focus on thoughts and beliefs are applicable to a wide array of issues. Because CBT has excellent empirical support, it has achieved wide popularity both for therapists and consumers. Those who may receive CBT training include psychologists, psychiatrists, social workers, and psychiatric nurses. Those seeking treatment using a CBT approach are encouraged to ask their therapist what CBT training they have had or to contact a Center for Cognitive Therapy and request a referral in their geographical location.

Reviewed by Debbie M. Warman, PhD and Aaron T. Beck, MD, June 2003 Section=About_Treatments_and_Supports&template=/ ContentManagement/ContentDisplay.cfm&ContentID=7952


This article is approved by the following for continuing education credit:

The American Psychotherapy Association provides this continuing education credit for Diplomates and certified members, whom we recommend obtain 15 CEs per year to maintain their status.

After studying this article, participants should be better able to do the following:

1. Gain familiarity with the successful use of CBT for psychotic symptoms.

2. Implement the treatment protocol in other cases of psychotic illness.

KEY WORDS: Cognitive Behavioral Therapy, psychosis, case study, treatment, Thematic Apperception Test, Schizophrenia, psychotherapy

TARGET AUDIENCE: Mental health professionals


DISCLOSURE: The author has nothing to disclose.


POST CE TEST QUESTIONS (Answer the following questions after reading the article, pages 18-27)

1. Why is it difficult to use standardized tests such as the MMPI or PAI with psychotic outpatients?

a) Reading is difficult for psychotic patients

b) Standardized tests should only be used with psychotic patients with negative symptoms

c) Standardized tests should only be used in the 'short form' format with psychotic patients diagnosed with positive symptoms

d) Standardized testing is difficult with such patients due to attention, concentration, and processing difficulties

2. How is expressed emotion (EE) usually evaluated?

a) Utilizing a mental status examination of the family

b) This is completed by counting the number of critical statements of hostility and emotionally loaded behavior within the family unit

c) Utilizing an emotionally focused family therapy paradigm

d) Utilizing a qualified doctoral trained psychometrist to assess family dynamics

3. What treatment components were included in the implementation of CBT in this article?

a) Rogerian therapy as a standard method of intervention

b) Psychoanalytic counseling methods as it pertains to the implementation of CBT

c) Restructuring; stress management via decatastrophizing; analysis of evidence and refutation of the delusional belief via alternate explanations; progressive deep muscle relaxation; thought stopping, counting and visualizing numbers; diaphragmatic breathing and challenging delusional cognitions

d) Jungian Shadow as it pertains to CBT

4. In the post acute phase of schizophrenia, reactions to schizophrenic outpatients are often characterized by:

a) Either extreme criticism {imputing a negative valence) or over involvement {imputing incapacity)

b) Indifference

c) Overly aggressive behavior to reduce guilt

d) Overly friendly behavior to reduce fear

5. Within the cognitive behavioral paradigm of treatment strategies, various authors have developed therapeutic approaches to emphasize the importance of the interactions between:

a) The patient's past practices and current biases

b) The patient's present practices as influenced by a dysfunctional family upbringing

c) The patient's future practices as influenced by their SAT scores and verbal fluency

d) Cognitions, emotions, and behavior


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Earn CE Credit

To earn CE credit, complete the exam for this article on page 28 or complete the exam online at (select "Online CE").

Don Hutcheon, EdD, RPsych, is a senior psychologist at Riverview Psychiatric Hospital, located in Coquitlam, a suburb of Vancouver, British Columbia. In addition to his job duties on three inpatient wards, Dr. Hutcheon has operated a part-time private practice and consulting business for the past five years.
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