Although CBGT for people with a psychotic disorder is the focus of this chapter, some of the research cited on CBGT for psychosis includes persons with bipolar disorder. Bipolar disorders are, according to the DSM-5, the modern understanding of the classic manic–depressive disorder or affective psychosis described in the nineteenth century. Although a psychotic episode is not part of the bipolar illness expression, the manic symptoms of inflated self-esteem, grandiosity, racing thoughts, and unpredictable behaviors can be sufficiently severe so as to resemble psychotic symptoms. In addition, psychotic symptoms, including both mood congruent and incongruent delusions and hallucinations, are commonly seen in patients with bipolar disorder.¹ Hence, bipolar disorders are often lumped in with psychotic disorders and referred to as severe and persistent mental illnesses.

I use the term psychotic disorders as an umbrella term encompassing some or all of the distinct DSM-5 diagnostic categories of the schizophrenia spectrum and other psychotic disorders. Bipolar disorders are included as well in some of the research I refer to.

Vulnerability to Psychotic Disorders

Similar to other mental health issues, problems with psychosis are best understood as a complex interaction of genetic and environment factors by which some individuals become susceptible to the development of negative symptoms during youth and adolescence. The negative symptoms seem to develop first and may be genetically determined (Rector, Beck, & Stolar, 2005).

Damage to certain brain structures or other structural abnormalities (e.g., enlarged ventricles in the brain) may be involved in a poorer integrative function of the brain and lead to limited resources for processing stimuli whether external to oneself (e.g., noticing unknown people laughing as they walk by) or from within one’s own mind and body (e.g., sensation of intense pressure building behind one’s temples). Some clients with psychosis talk about a sense of being unable to filter what to pay attention to and what to ignore (e.g., a quick decision to ignore passersby who laugh as opposed to personalizing it by assuming they are “laughing at me”). It is as if the filter mesh is not tight enough and one therefore “takes in too much” and easily becomes overwhelmed. These processing deficits seem to render people with psychosis more vulnerable to a number of cognitive biases (e.g., a reasoning bias where one jumps too quickly to a conclusion of “people are laughing at me” without engaging in a process of more careful review of evidence).

Contemporary research in cognitive neuroscience reviewed by van der Gaag, Nieman and van den Berg (2013) consistently find decreased prefrontal cortex activity and increased amygdala activity in people with psychosis. Whereas the amygdala is the brain structure associated with emotional arousal, the prefrontal cortex regulates emotion by engaging in higher-level cognitive abilities, such as the ability to look or plan ahead and put a present moment of distress into a larger context. Medication and CBT alike is hypothesized to work by strengthening the cortical projections from the prefrontal cortex to the amygdala in an attempt to allow reason to override the automatic fear response (van der Gaag et al., 2013).

As for environmental factors, people with a brain vulnerability predisposing them to overarousal and stimuli overload naturally do better in supportive, calm, and predictable environments. Environmental experiences of any form of abuse, including verbal, can have catastrophic consequences for an already vulnerable brain. Research on environmental factors suggests that patients with psychosis have had more traumatic experiences—including coercive treatment interventions—compared to the general population and thus often also experience posttraumatic stress symptoms and show a greater sensitivity to a variety of triggers and stressors (Lu et al., 2011; Mueser, Lu, Rosenberg, & Wolfe, 2010). Environmental factors can thus play a role in both the cause and maintenance of psychotic illnesses.

CBT for Psychosis

The first 5 years after onset of a psychotic episode are a critical time for preventing further deterioration. While a number of interventions including supportive therapy, case management, social skills training, and family psychoeducation are helpful immediately following a first episode, CBT may be uniquely beneficial for those with prodromal symptoms. These are people who are at risk for a first episode of psychosis (van der Gaag et al., 2013) and who continue to experience residual symptoms after their first episode, that is, those with recent onset, as opposed to those who are deemed chronically ill (Erickson, 2010; Zimmermann, Favrod, Trieu, & Pomini, 2005).

CBT seems moderately well supported even for those with chronic psychosis (Saksa, Cohen, Srihari, & Woods, 2009). Although CBT initially targeted the positive symptoms of psychosis, it is now also recognized as an effective treatment for the negative symptoms of psychosis (Rector, Seeman, & Segal, 2003). CBT can further be of benefit to those who refuse medication (Christodoulides, Dudley, Brown, Turkington, & Beck, 2008) or have comorbid conditions (Barrowclough et al., 2009). Mostly, CBT has been used as an adjunct to antipsychotic medication therapy for various forms and levels of severity of psychotic disorders, especially if there are no comorbid problems of addiction or other mental health issues (Wykes, Steel, Everitt, & Tarrier, 2008).

As a result of the consistent evidence on the effectiveness of CBT for psychosis as either a stand-alone or adjunctive treatment, government-approved clinical expert panels in both the United Kingdom (National Institute of Clinical Excellence, 2009) and the United States (Lehman et al., 2004) recommend that CBT be offered to people diagnosed with a psychotic disorder to promote recovery. This applies to those with persisting positive and negative symptoms and to those whose symptoms are in remission. Clinicians welcome these recommendations but are left with questions about what symptoms to target, which components of CBT are especially helpful for what type of psychosis, how to alter the delivery of CBT interventions to people whose insight is different from those with depression and anxiety, and how to maximize efficiency and cost-effectiveness by using a group format.

Standard cognitive and behavioral strategies used for depression and anxiety took longer to become applied to psychosis. This was a result of clinicians and researchers (erroneously) assuming that the positive symptoms of psychotic illnesses, such as hearing voices (e.g., a voice that suggests one should kill oneself) or having delusions (e.g., believing that one’s neighbor has planted a camera in one’s apartment), were encapsulated, or calcified, by the illness and therefore not responsive to any psychological intervention. When clinicians discovered that psychotic symptoms are not best understood as petrified phenomena of the mind but rather as malleable to varying degrees depending on the afflicted individual’s level of insight, clinicians began applying and researching CBT principles and practices, and the evidence for the helpfulness of CBT mounted rapidly. When clinicians help clients notice links between momentary feelings of anxiety and distress accompanied by an increase in psychotic experiences, they are highlighting the flexibility of psychotic symptoms. As clients become increasingly aware of these connections, CBT therapists proceed to explore whether certain thoughts, or thinking biases, may support and escalate the strong (delusional) beliefs (van der Gaag et al., 2013; Tai & Turkington, 2009).

Initially, CBT for psychosis focused on improving coping and life skills as well as increasing behavioral activity. This behavioral focus on improving functioning, especially social withdrawal and apathy, was in part based on assumptions about the impossibility of accessing the belief system of people with psychotic symptoms. Clinicians now recognize the additional importance of beliefs and of addressing them therapeutically. The cognitive theory of psychosis suggests that in addition to any neurobiological vulnerability, specific cognitive beliefs and appraisals play a prominent role. Most often, people with, or vulnerable to, psychosis have extremely low expectations for deriving pleasure or success from social interaction and goal-oriented pursuits. Although people who experience psychosis may have a lower capacity for sustaining concentration, they may also exaggerate their limitations because of their defeatist thinking style (Rector et al., 2005). For example, a woman who has given up on working with an employment agency may tell herself that there is no point in carrying on as she does not believe she could manage showing up 3 days a week for part-time work. In the absence of any opportunity to gently challenge this belief, she will only become increasingly convinced of her ineptitude.

CBT for psychosis typically includes cognitive and behavioral interventions targeting both positive and negative symptoms, using some or all of the following components: (a) the establishment of a solid psychotherapeutic alliance; (b) psychoeducation with discussion of how biological, social, and psychological factors all play a role; (c) reduction of stigma by normalizing as much as possible symptoms of psychosis; (d) delivery of cognitive and behavioral skills; (e) attention to reducing any comorbid symptoms of anxiety and depression; and (f) relapse prevention education (Rector, 2005). Books such as Cognitive Behaviour Therapy for Psychosis (Fowler, Garety, & Kuipers, 1995) guide clinicians through all these interventions. Similar to many CBT clinicians, I was mainly trained in CBT for anxiety and depression and recall feeling buttressed by, and slavishly following, Fowler and colleagues’ guide with some of my first clients with psychosis.

One was a 69-year-old woman with chronic waxing and waning symptoms of paranoia. She had become convinced that her upstairs neighbor had rigged a tiny camera in her apartment and got some special thrill out of spying on and mirroring her every move. My client would tell me that if she got up to go to the bathroom at 3:00 a.m., so would her neighbor. If she started listening to the radio at noon, so would her neighbor. My client was impressed with how devious this neighbor was by acting as if nothing was going on when she would invite her up for tea or offer a ride to the shopping mall. Using classic cognitive interventions of gathering evidence for and against the possibility that the neighbor was spying, self-monitoring with careful recordings of neighbor coincidences, reviewing cognitive biases such as jumping to conclusions, and discussing the neighbor’s motivations, my client slowly became more accepting of the possibility that maybe she was not that fascinating to follow (her rediscovered sense of humor was further helpful and relieving) and perhaps she and her neighbor were just two elderly people doing some of the same things some of the time at the same time. When applied to psychosis, CBT engages clients in collaboratively challenging their interpretations of events and experiences and assists them in developing more realistic alternatives to delusions or paranoid thinking.

As previously mentioned, the earlier CBT focus was on the positive symptoms, but ongoing research and clinical practice have uncovered the possibility that many factors in addition to the content and style of a person’s thinking may play a role in the development and expression of psychotic disorders. It may be just as therapeutic and helpful to target clients’ often negative expectations of themselves and others rather than zooming in on hallucinations or delusions too quickly (Rector, 2005). Encouraging outcomes from CBT research suggest that people with psychosis can identify and pursue life goals in the face of residual psychotic symptoms (Cather, 2005) or symptoms suggesting a risk for a psychotic episode (van der Gaag et al., 2013).

CBT that focuses on the negative symptoms pays attention to a number of factors, including people’s level of interpersonal adjustment and comfort, their self-esteem and self-acceptance, and their ability to recognize, identify, and regulate their feelings. Unrecognized feelings of threat seem to especially worsen symptoms. The newer CBT-based therapies for psychotic disorder address these by, for example, adding a narrative enhancement module to the traditional CBT or a self-compassion component. These newer approaches will be described in the following text in the context of group CBT for psychosis. The CBT group for psychosis seems especially well equipped to target negative symptoms, and with this in mind, we may see a renewed clinical interest in and success with CBGT for psychosis. For people with psychotic problems, interactions with other human beings are often their main source of stress and the reason many withdraw from human gatherings as much as possible. Before we turn to the literature on emerging trends in CBGT for psychosis, I offer some comments on the assessment for group readiness for people with psychosis.

Assessment

Unlike the standard clinical intake assessment, the psychosis group intake clinician keeps the focus on present functioning and does not attempt to follow a case formulation approach where predisposing, precipitating, perpetuating, and protective factors are summarized and reviewed with the client. People with psychotic problems are not expected to have this level of interest or insight, although they may develop it over the course of successful therapy. Given that CBGT for psychosis also works with the here and now, it is possible for people with limited insight into their illness to participate in and benefit from groups.

Clients with psychosis who are interested in a group usually already have a small team of caretakers supporting them. This team should at minimum include a psychiatrist who is responsible for monitoring medication and a case manager who assists the client with their needs for housing, income assistance, working, and transportation. Thus, there is usually ample material and sources of information making the group assessment less onerous. However, if the chart information about the client is limited, the Client’s Assessment of Strengths, Interests and Goals (CASIG-SR; Lecomte, Wallace, Caron, Perreault, & Lecomte, 2004; Wallace, Lecomte, Wilde, & Liberman, 2001) is a helpful template for conducting an assessment of the client’s level of functioning and motivation for making changes. The CASIG-SR comes in both a clinician-administered and a client self-report format that covers many areas, including goals for physical health (e.g., Would you like to improve your physical health in the next year?) and satisfaction with several areas such as money (e.g., In the past 3 months, did you keep your money in a safe place?), medication (e.g., Do you feel good about your current medications and their dosages?), and care of personal possessions (e.g., In the past 3 months, did you wash your clothes at least once in the past 2 weeks?).

A more specific symptom measure often used as a treatment outcome measure is the Positive and Negative Syndrome Scale (PANSS; Kay, Fiszbein, & Opler, 1987). The PANSS includes seven positive items (e.g., delusions), seven negative (e.g., blunted affect), and 16 general psychopathology items (e.g., anxiety, guilt, tension). Each item is rated by a clinician on a scale from 1 to 7 with a score of 1 indicating the symptom is “absent,” a score of 5 indicating “moderate–severe” symptoms, and a score of 7 indicating “extreme” symptoms. The PANSS has been successfully used as an outcome measure in CBT trials for psychosis for both individual (Leucht et al., 2005) and group treatment (Klingberg et al., 2010). Another commonly used clinician-administered assessment tool in CBT trials is the Psychosis Rating Scale (PSYRATS; Haddock, McCarron, Tarrier, & Faragher, 1999). The PSYRATS focuses on different dimensions of delusions and hallucinations and is therefore useful in therapy trials.

The group intake clinician explains what the group is about. If the intake clinician is not one of the group therapists, it is critical that the intake clinician who does the assessment has detailed and accurate information about the group so that this can be shared with the client. Ideally, a brief written description of the group will be given to the client. It is important that this individual pregroup orientation mirrors the upcoming group in terms of frankness and directness in explanation and answering questions. It is a good idea to reinforce the team approach to the client’s care and get permission, if not already in place, for the group leaders to connect with the client’s case manager and psychiatrist. In order for these caregivers to optimally support their client in attending the group, they will need to know the content and approach of the group. Once the group has started, it is helpful if the case manager or psychiatrist continues to show an interest in the group and willingness to review group materials with the client.

Increasing Evidence Supports CBGT for Psychosis

The first CBT groups were specifically designed for targeting the positive symptoms of auditory hallucinations, Hearing Voices groups (Chadwick, Sambrooke, Rasch, & Davies, 2000; Wykes, Parr, & Landau, 1999).² In contrast to research on individual CBT, the initial empirical support for a group format was weaker (Johns & Wykes, 2010). But the past 5 years have produced research challenging the notion that individual CBT is, as a rule, superior to group CBT for psychosis. For example, Saksa and colleagues (2009) reviewed eight studies on individual CBT and five on group CBT for early psychosis. Their results suggest that the group format may be more effective and preferable—although the results need to be replicated given that some of the studies lacked in methodological rigor. The authors speculate about the positive effects of various group process factors. Specifically, group members with psychosis may be more receptive to CBT concepts when they are reinforced by peers and a sense of learning and modeling new coping strategies together. The authors further suggest the group setting may be experienced as less intense—and less threatening—compared to directly facing one therapist, as is the nature of individual CBT. In a group, it is easier for members to vary their level of engagement, and even though some members are more passive and only listen, they may still benefit.

Other studies have also found a group CBT format effective for both positive and negative symptoms when compared to standard psychiatrist and case management care for people with early onset of psychosis. But group CBT was not as effective for those who had a psychotic illness for longer periods (Barrowclough et al., 2006; Lawrence, Bradshaw, & Mairs, 2006). To test the possibility that CBGT may be more effective if the stage of psychosis (i.e., early, late, chronic) perspective is considered, Gaynor and colleagues compared CBGT for 25 people with early onset to 40 clients with stable psychosis (Gaynor, Dooley, Lawlor, Lawoyin, & O’Callaghan, 2011). People with bipolar disorder were included in this study. Gaynor and colleagues reported significant improvement in positive symptoms and depression as well as anxiety in first-episode psychosis, as well as among those with ongoing, stable psychosis. But only first-episode clients experienced an improvement in negative symptoms.

Most recently, Chung, Yoon, Park, Yang, and Oh (2013) treated 24 patients with first-episode psychosis in 12 weekly group sessions. They followed a manual that includes four components: (1) enhancing emotional flexibility, (2) enhancing thought flexibility, (3) enhancing personality flexibility, and (4) finding a positive meaning in the illness. Results showed significant improvements in positive and negative symptoms according to self-reports, as well as improvements in emotional functioning. There was a special emphasis on targeting positive symptoms related to ideas of reference by using humorous, didactic cartoons and video clips. The authors suggest that group members with psychosis may derive more benefits from group-related factors (e.g., the experience of helping others) than manual-based treatment factors (e.g., CBT psychoeducation about the connection between thoughts, feelings, and behaviors). This study did not include a control group, and one must thus be careful drawing conclusions about the unique effectiveness of CBGT.

The reviewed research suggests that CBGT may be especially helpful for people who are in the early stage of their psychotic illness. But is CBGT superior to other forms of group therapy for psychosis?

Some of the first clinical outcome studies on group CBT for early psychosis were conducted in Canada by Tania Lacomte and colleagues. They include a protocol consisting of 24-session CBGT with a focus on goal setting, thought challenging, and self-esteem. Although some have questioned the research methodology for relying too heavily on small samples and qualitative methods, and others have questioned whether the interventions are truly CBT because the modules also include a focus on self-esteem, the outcomes consistently support this group format (Lecomte, Leclerc, Wykes, & Lecomte, 2003). When this CBGT approach has been compared directly to another group approach focusing on social skills training, the two were equal in decreasing positive symptoms. But the members of the CBT groups did better with their use of active coping strategies during stressful times and enjoyed an improvement in negative symptoms due to better self-esteem (Lecomte et al., 2008). At 1-year follow-up, there were further gains in negative symptoms, including social support and insight, but no further improvement in positive symptoms (Lecomte, Leclerc, & Wykes, 2012). The 1-year follow-up study was hampered by dropouts and thus a small final sample size, which makes it difficult to draw firm conclusions.

Another study comparing CBGT directly to a “goal-focused supportive contact” group intervention was not able to conclude that CBGT was superior (Granholm, Ben-Zeev, & Link, 2009). Both groups achieved improvements in beliefs about social competence, which were associated with enhanced functioning. These results lead the authors to wonder if the nonspecific social interactions during group therapy lead to increased beliefs about competence, regardless of whether these beliefs are specifically targeted, as in CBT, or indirectly addressed in supportive-type group therapy. I wonder if the lack of difference could also be a result of the goal-focused comparison group including strong elements of CBT, given that CBGT is both a goal-focused and supportive treatment approach.

The Granholm studies suggested that the social support felt in the groups helped members to develop skills and confidence to reach out, ask for help, and surround themselves with caring and understanding family and friends. Other clinical researchers have similarly found social support to be helpful for warding off self-stigmatizing. Klingberg and colleagues (2010) concluded that CBGT was effective in delaying relapse due to improvement in negative symptoms. That is, the CBGT clients had more helpful social contacts compared to those who received standard psychiatric care. The CBGT in this study consisted of psychoeducation, social–emotional skills training, social interaction addressing leisure, living situation, and employment, family education sessions, and stress management.

Narrative enhancement and cognitive therapy

An explicit approach to becoming accepting of one’s unique life story is group-based narrative enhancement and cognitive therapy (NECT; Yanos, Roe, & Lysaker, 2011). This program runs for 18–20 weeks, with each session lasting 90 minutes. The treatment manual includes three sessions of psychoeducation with an emphasis on recovery and the inaccuracy of stigmatizing views of severe mental illness. The next eight group sessions focus on standard cognitive restructuring, which supports group members in challenging dysfunctional cognitions about themselves and their illness (e.g., “I have a mental illness and don’t expect to ever recover”). The last eight group sessions support group members in constructing a personally useful and meaningful narrative of themselves, their illness, and their relationship to their illness. These narratives may be verbally shared, written down, or both. The stories can be about past or recent events; they focus on bringing together clients’ previously fragmented and isolated aspects of their experiences through the telling of a coherent story. For example, a group member shared a story about how his brother “freaked out” and refused to let his children, the group member’s nieces and nephews, visit him alone after learning about his diagnosis. The rest of the group offered reflections and feedback, and in this case, helped the member to not buy into stereotypical and often erroneous beliefs about psychosis. The group also supported the member in moving from a passive stance to becoming more assertive both in his treatment and in interactions with family members. The latter involved telling family members more about his treatment and about situations that are especially anxiety provoking for him. The ultimate goal in the NECT group is thus to offer group members opportunities to practice their skills at negotiating and rewriting their personal stories. This practice helps to internalize the confidence-boosting role of the narrator. Some pilot studies, which included people with both psychotic and bipolar disorders, have yielded good outcomes (Yanos et al., 2011). The NECT approach is intended for people who are in a stable phase of their illness and not for early or acute stages of psychotic illness.

Compassion-focused therapy

The aforementioned example included a person experiencing a number of threat emotions, such as anxiety and anger, associated with a fear that his brother perceived him as potentially harmful to children. Based on evidence that people with psychosis struggle with processing and regulating perceived threats, the compassion-focused therapy (CFT) approach was developed (Braehler et al., 2012). This approach supports people with psychosis in expanding their capacity for self-calming—including reaching out to others, because supportive social relationships can also be calming. CFT recognizes that some people with psychosis who easily experience shame and self-criticalness also have the hardest time using supportive relationships as a means for calming. The group CFT protocol consists of 16 group sessions and integrates aspects of mindfulness and group processes in psychosis (Braehler, Harper, & Gilbert, 2013). The first third, called the formation phase (sessions 1–5), explores the impact the psychosis has on group members’ lives and focuses on reducing shame, stigma, and increasing skills for self- and other compassion. The middle phase (sessions 6–13) include a gradual development of compassion by exploring the nature of compassion and how that might be expressed in the group and used for oneself. Compassion skills such as mindfulness, appreciation, imagery, attention, positive behaviors, and reframing are practiced and applied in relation to the internal and external threats and related difficulties members bring up. These difficulties typically include shame, social anxiety, paranoia, self-attacking, hostile voices, and poor motivation. The ending phase (sessions 14–16) involves expressive writing tasks to help members reflect on and integrate changes in their recovery from a compassionate stance. The developers of this protocol emphasize that throughout the group facilitators foster a caregiving mentality by developing a compassionate group mind. A compassionate group mind involves supporting members’ interactions and capacity to relate to one another. A large part of the CFT group involves helping members to become aware and accepting of their own needs and to respond to themselves with warmth and compassion. Any self-attacking, or inner bullying, is seen as a psychological vulnerability factor that can increase the potential for relapse. After practicing being more forgiving of oneself, people with a vulnerability to a psychotic episode may become more confident in expressing their needs to those around them. The following exchange illustrates how the group can help a member, Sebastian, become more forgiving of and compassionate toward himself:

Therapists:

In our last session we talked a lot about how hard it can be to tell family members that you cannot always participate in family events as much as they want you to. We are curious to hear if you have noticed any change in the way you show care for yourselves when you sometimes have to disappoint others.

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