Psychotherapy Said to Be Key to Successful Psychosis Treatment

Once, when Michael Garrett, M.D., met with a new patient, she told him her cat planned to murder her. “She didn’t take action to get rid of the cat, but was frozen in this state of terror,” Garrett recalled.

Garrett began treatment with a cognitive-behavioral therapy (CBT) technique. He asked how the cat planned to kill her, and when the patient said the cat would bite her jugular, Garrett asked where her jugular was. The patient didn’t know the answer. “And then I was able to make an intervention,” said Garrett, professor emeritus of clinical psychiatry at SUNY Downstate Medical Center. “I said, ‘You don’t quite know where your jugular is, but if the cat is going to do this to you, it has to know exactly where your jugular is.’ ” At their next appointment, the patient told him that the cat still had the intent to kill her, but she now believed the cat lacked the means to do so.

Garrett described this experience in May during the APA Annual Meeting session “Psychotherapy for Psychosis: Perspectives on Current Interventions and Future Directions.” In this case, the CBT technique had given Garrett and the patient time. She was no longer terrified, and he was able to work with her to better understand what the cat delusion represented to her and why she had developed the belief that it would kill her.

“I use CBT techniques to help patients understand the literal falsity of delusional beliefs, and then I use a psychodynamic approach to help them understand the figurative truth of their delusional experiences,” Garrett said.

Robert Osterman Cotes, M.D., chaired the session. “The reality is psychotherapeutic approaches are a critical element of care for people experiencing psychosis and are needed now more than ever,” said Cotes, an associate professor at Emory University School of Medicine in the Department of Psychiatry and Behavioral Sciences and the director of the Clinical and Research Program for Psychosis at Grady Health System.

Sarah Kopelovich, Ph.D., pointed out that, according to a recent point-prevalence estimate she conducted, only 0.57% of the public behavioral health workforce is trained in CBT for psychosis. That means that there are only about 15 clinicians with such training for every 10,000 individuals with psychosis in the United States, she said.

“We definitely cannot train ourselves out of that hole; it is going to take a broad-scale effort with some really thoughtful and creative approaches to policy and implementation research,” said Kopelovich, an assistant professor in the Department of Psychiatry and Behavioral Sciences at the University of Washington School of Medicine, where she also co-leads the Supporting Psychosis Innovation through Research, Implementation, and Training (SPIRIT) lab.

The participants agreed that psychotherapy can engage patients, teach them important skills, and help them focus on goals, which are essential to recovery. “There is nothing like a human connection,” said Kim Mueser, Ph.D., a clinical psychologist and professor at the Center for Psychiatric Rehabilitation at Boston University. “Connecting with another person, in and of itself, is useful and very important, especially for people who have had a psychotic episode or psychotic symptoms” (see Special Report beginning).

Psychoeducation is also highly valuable, Mueser added. Understanding symptoms and diagnoses helps normalize patients’ experiences and reminds them they’re not alone. It allows them to process their experiences in a meaningful way, perhaps by understanding the circumstances in which the symptoms began to appear or the traumatic experiences that may have shaped their beliefs, he said.

Many of the speakers referenced a strategy developed by Eric Granholm, Ph.D., known as the “3C’s,” in which the clinician teaches the patient to catch it, check it, and change it (“it” refers to a patient’s unhelpful thought). The strategy is part of Granholm and colleagues’ Cognitive-Behavioral Social Skills Training intervention manual. Granholm is a professor of psychiatry and director of the Center for Mental Health Technology at the University of California, San Diego, and the chief of psychology and co-section chief of psychosocial rehabilitation and recovery services at the VA San Diego Healthcare System.

If patients are having an unwanted thought, they can catch the thought by asking: What is going on in my mind right now? Checking it involves reviewing the evidence for or against the belief, such as by asking: Is this person really trying to harm me? Finally, changing it means switching the thought to one that is more accurate based on the evidence.

“Some people have certain thoughts about voices that are key to go after,” Granholm said. “One is the belief that the voices are from very powerful beings, like a demon or a god. The implication is they could do harm or follow through on threats they’re making. But regardless of the source of the voice, the therapist can [address] the idea that the voice is a powerful being. Is there evidence the voice can really hurt you? If you can make the voice go away by listening to music or doing another activity, how could it be a powerful demon or god? It must not be very powerful.”

An all-too-common sequence for people experiencing psychosis is being hospitalized and receiving medication, followed by short-term improvement but not long-term recovery, Garrett said. He noted an insidious pessimism that attends the treatment of people suffering from chronic psychosis. Medications are sometimes lifesaving, he continued, but their therapeutic effects have limits. “Which is not to say there won’t be improved biological treatments over time, but there’s so much we can do for people right now, and the reason they’re not getting better is partly what [Kopelovich] said: We don’t have [enough] people to do the work.”

When people with psychosis don’t get better, their lack of improvement is often labeled as treatment resistance. But Garrett said he considers this label misguided.

“It’s the system that’s resistant to providing the resources people need to really recover their lives,” he said. ■