CBT, Psychosis and Attitudes of the Medical Community

Cognitive Behavioral Therapy (CBT) is a very effective method in psychology to combat psychosis. CBT is effective because it can be used independent of medication or in conjunction with it. In order to understand this method of therapy it is important to compare it to others and examine the goals. Further, the attitudes of the medical community, patients and a respect for individualism when using CBT can help immensely with treatment. This is of great importance considering that the purpose of CBT is to alter thinking patterns, which are distinctive to each person.

CBT is a middle-ground approach with a simple definition. “If you learn to think and act differently, then your mental and emotional problems may disappear” (Unger 2). In terms of other models, the balanced approach of CBT becomes evident. For example, two competing ideas: shame & blame and the medical model are on the extreme fringes of methodology for psychosis. Shame & blame, as its name implies, seeks to define psychosis, or any form of mental illness, as a choice made by the patient. The medical model takes all responsibility away from the patient and chalks their mental illness up to abnormal brain function where the sole solution becomes medication. Finally, CBT, clearly states that blame should not be placed on the shoulders of the patient but, rather, through cognitive awareness, the patient can learn to maximize their chances of recovery through the application of changing their thoughts (Unger 4). In terms of goals, CBT is commonly misunderstood. “…NOT to eliminate voices or hallucinations… rather the focus is on changing beliefs and associated behaviors around the voices or other hallucinations” (Unger 59). Therefore, a great deal of the effectiveness of CBT has to do with changing the internal dialogue of the patient regarding their experiences of disillusionment with reality. Additionally, in order to increase the effectiveness of CBT, the attitudes of medical experts and patients is paramount.

In order for the application of CBT to be successfully implemented, the attitudes of medical experts using CBT have to be positive and adaptable to each individual patient. Schizophrenia, for example, illustrates how important it is for therapists to attempt to familiarize themselves with the individualized personalities of each patient. “…with schizophrenic patients, the therapist must make an effort to build an alliance with the person behind the illness” (Johannessen, Martindale, and Cullberg 35). Arguably, this is the first step to a shift, if needed, to a positive and inclusive attitude on behalf of the therapist who is attempting to utilize CBT to treat their patient. Another important factor is to separate the person from their psychosis. All too often the mental illness takes precedent over the person. Instead of a patient being viewed as having a disease they are looked at as the disease itself. This can-do irreparable harm to an already fragile situation. Fortunately, there are a couple different models available that therapists can use to pinpoint personalities and use CBT in the most constructive way possible for the patient.

The first model for clarity is called the disposition or vulnerability model. This model attempts to explain how, for some patients, their specific personality type can be a precursor to psychosis. In other words, analyzing a particular patient using this model is appropriate when it is clear that their personality type is related to their psychosis. Further, the patient is able to separate, to varying degrees, their personality from their psychosis. In terms of CBT, this can be very helpful, considering personality and thought patterns are somewhat correlated. The second model is called the personality/psychosis integrated model. In this model, the line between personality and psychosis is often blurred for the patient, making the use of CBT difficult. “The patient has the feeling of being another person; that his or her own personality has disappeared, or different personalities are present at different times” (Johannessen, Martindale, and Cullberg 38-39). Obviously, the deeper a particular patient is in their psychosis, the harder it is to introduce CBT as an effective strategy since the approach is contingent on the realization of thought patterns and the ability of a person to distinguish between their psychosis and reality. It is likely that CBT would have to be paired with medication in order to treat a patient whose personality more closely resembles the second model. In addition to baseline models, the application of CBT by healthcare professionals must be customized when therapy begins.

Ironically, one obstacle that can sometimes get in the way of implementing CBT is the medical professional’s reluctance to diagnose a patient psychosis. One country where this is particularly troubling is Japan. “…only 7% of psychiatrists reported that they always inform their patients of a diagnosis of schizophrenia. This could be interpreted as the psychiatrist reinforcing the acceptability of the associated stigma rather than attempting to challenge it” (Patel 213). Removing the embarrassment and/or fear experienced on behalf of the medical professional entrusted with caring for a patient with psychosis is the key to developing a healthy attitude in framing an effective CBT program. When medical professionals succumb to the commonly misunderstood factors of psychosis, the consequences are severe. “…health outcomes for patients with schizophrenia were adversely affected by ‘authoritarian’ attitudes (patient held accountable for own behaviour) whereas high ‘protective benevolence’ (friendly non-punitive, laissez-faire approach) was associated with improvement” (Patel 216). Due to the already delicate mental state of the patient, the medical professional needs to be balanced and positive. It is crucial that an attitudes of uncomfortableness are altered, if need be, at the beginning of CBT treatment. While the attitudes of medical professionals are undoubtedly important for CBT success, the attitudes of patients are equally important.

In the early 1990s, a study was conducted to determine 50 patients’ attitudes towards their psychosis, specifically hallucinations. Interestingly, over half of the patients studied attributed their hallucinations to positive benefits. This realization could be immensely helpful to medical professionals in their strategy when using CBT. Further, over 25 percent of respondents stated that hallucinating was preferable to living life devoid of hallucinations. The top three benefits of hallucinations for these patients were relaxation, companionship and financially oriented (Miller, O'Connor, and DiPasquale 586). However, adverse effects were also recorded. Ironically, two of the top three problems caused by hallucinations were on the benefits list. Over 90 percent of participants stated their hallucinations caused significant financial hardships and over 80 percent stated emotional turmoil was caused by their hallucinations (Miller, O’Connor, and DiPasquale 587). What can be observed from this is, hallucinations are often seen as a double-edged sword in the minds of patients who experience them. Therefore, CBT can be used as a tool to illuminate a patient to recognize that, while their hallucination sometimes provides temporary relief, the problems remain, and are in fact heightened by the positive perception of the hallucination.

Just as the perceptions surrounding psychosis, particularly from patients, is variable, the goals for recovery are also variable. “Recovery can be defined in various ways and may hold different meanings for different people. In psychiatric terms, it may be defined primarily as the absence of particular symptoms or diagnostic criteria. From a survivor perspective, it may be seen as regaining an ability to function in society and achieve one’s life goals” (Thornhill, Clare, and May 182). Incorporating this principle into CBT is critical to the success of treatment. Fortunately, the nature of CBT is flexible since the primary goal is to shift thought patterns. Obviously, thought patterns and degrees of struggle regarding psychosis are non-uniform from person to person. This allows a wide spectrum of applicability for CBT.

A study published in the journal of Anthropology & Medicine examined the personal projections of recovery from 15 patients. Some patients in the sample identified themselves as being on the road to recovery while others considered themselves recovered from their psychosis (Thornhill, Clare, and May 183). Four questions were asked to each patient. “What does ‘recovery’ mean to you? What is it you feel you have recovered from? What helped, or did not help, at different stages in your recovery? Were there any particular turning points” (Thornhill, Clare, and May 185)? Within these parameters, the study produced results categorized as enlightenment, endurance and escape regarding recovery. Most of the patients in the study expressed reaching enlightenment as their goal to overcoming psychosis. Within the study, enlightenment means, “…the sudden or gradual dawning of understanding, bringing a new perspective” (Thornhill, Clare, and May 189). The second most common theme of recovery was endurance. Within the study, endurance means, “…an acceptance of life as a struggle…an acknowledgment of the need to contend with ongoing difficulties” (Thornhill, Clare, and May 190). In other words, these patients saw their psychosis as ongoing and never ending. Coping was the ultimate sign of recovery for them. Finally, the least common theme was escape. Within the study, this was described as, “…breaking free from imprisonment…” (Thornhill, Clare, and May 187). This perception of recovery essentially meant breaking free from all perceived traps such as hospitalization and the psychosis itself. Through understanding these different perceptions surrounding recovery, therapists can begin to personalize their approach to CBT.

What makes CBT one of the most effective strategies for coping with psychosis is its flexibility through application. For medical professionals, this is a dire point to recognize. For patients, this is an immense strength for personalized recovery. Ultimately, the effectiveness of CBT is contingent upon the attitude and understanding between the medical professional administering it and the patient receiving it.

Works Cited

Johannessen, Jan O., Brian Martindale, and Johan Cullberg. Evolving Psychosis: Different Stages, Different Treatments. 1st ed. London: Routledge, 2006.

Miller, Laura J., Eileen O'Connor, and Tony DiPasquale. "Patients' Attitudes towards Hallucinations." The American Journal of Psychiatry 150.4 (1993): 584-88. ProQuest. 1 Mar. 2014.

Patel, Maxine X. "Attitudes to Psychosis: Health Professionals." Epidemiologia E Psichiatria Sociale 13.4 (2004): 213-18. 5 Mar. 2014.

Thornhill, Hermione, Linda Clare, and Rufus May. "Escape, Enlightenment and Endurance: Narratives of Recovery from Psychosis." Anthropology & Medicine 11.2 (2004): 181-99. 1 Mar. 2014.

Unger, Ron. Cognitive Therapy for Psychosis: An Individualized Approach for "Extreme States" PPT.