Can Frontline Clinicians in Public Psychiatry Settings Provide Effective Psychotherapy For Psychosis?

In the U.K. all clinical psychologists, regardless of their final specialty, leave graduate school with competency in CBT and some knowledge of CBTp. They also leave graduate school with competency in at least one additional therapeutic modality, and many psychologists describe themselves as “integrative”. There is also extensive training in person-centered practice and the recovery model, which fits with this “integration.” Most psychology graduate school programs have a mildly anti-medical or antipsychiatry model, and some are very outspoken about it. There is little debate in the U.K. about CBT vs psychodynamic psychotherapy. Most health care professionals believe that CBTp works, but they have not been trained in its use.

I was worried that things in America could be a little different, and that I would be pulled into endless discussions about psychodynamic psychotherapy and why I thought CBT was better for treating psychosis. I also worried some clinicians would adhere staunchly to the medical model, believing that psychotherapy could not be done at all with someone with psychosis and that it was a waste of energy to try. If I were to flag my own thinking styles here: overgeneralizing, fortune telling and a little catastrophizing.

My second fear concerned quality control amongst therapists. In the U.K. only clinical psychologists are trained in graduate school to do therapy. Although, social workers, nurses, and other mental health professionals have been able to train post-qualification in CBT, they are very closely regulated, and need to prove their credentials to be hired in the National Health Service as a therapist. I was worried that in the U.S. any licensed professional could just write “trained in CBTp” on a resume and people would think him or her competent. I was concerned that anyone I trained might do this without my knowledge. It puts a huge pressure on me as a trainer. My negative automatic thoughts were:

I have now been in the U.S. for almost seven years, during which time I have taught more than 100 mental health professionals. I have trained clinicians in individual therapy for outpatient settings, in CBTp informed milieu interventions for the inpatient unit and day treatment program, in group therapy for both inpatient and outpatient settings, psychology interns and externs, psychiatry residents, peer counsellors, psychiatry technicians, nurses, creative arts therapists, social workers, nurse practitioners, psychologists, psychiatrists. My earliest, and perhaps most challenging, memories come from the first workshops I did. In each workshop I was aware of working hard to get some response from the audience. I recall presenting a slide about how delusional beliefs exist on a continuum and reporting data on how common specific beliefs were in the general population. I referenced a statistic about belief in ghosts; one clinician shouted out “. . . what about the Holy Ghost?” To encounter therapists expressing personal religious beliefs was a new experience for me. In the U.K. it was uncommon to talk about religious beliefs.

On completing the workshops I distributed feedback forms, but few were returned to me. Yet in the weekly, hour-long group consultation there was a shift. Staff members would bring me their most difficult cases, often seemingly throwing down the gauntlet. We would think about them, and I would share suggestions and strategies, often with anecdotes from my experience in public healthcare in the U.K. and somehow the staff found the motivation to try these strategies out. They worked, and then the staff was hooked! Because CBT for psychosis works, practitioners want to use it. But a majority had no formal training in how to work with severe and persistent mental illness. These clinicians may feel ineffective or even traumatized by their work. They come to embrace the trainer and the material, and that is powerful stuff.

Breakthrough Moments, and Inspirations. Another memory that has stuck with me over the years was supervising master’s level mental health clinicians providing group and individual therapy in an outpatient clinic. Counts of patient visits and billing were the key requirements of the clinic, so little attention was paid to the quality of the therapy being provided. Most of the time clinicians were providing “supportive therapy” and the majority of their daily effort was spent getting patients into the treatment room, but there was little clarity about what constituted quality care once the patient sat down. I had been teaching specific CBTp techninques, including agenda setting and how to take a patient’s “crisis of the week” and using the CBT triangle, drill down on a particular episode, elicit thoughts, feelings and actions, illustrate the model and begin to build change. I remember the first time a therapist was able to do this effectively. She was so excited she could not wait for the supervision session. Not only was she able to do something that she believed would be difficult and time consuming, but also the patient, with whom she had been working for years (with no real apparent change) was suddenly able to see something new.

I have lost count of the number of times a staff member stops me after I have given a workshop, presentation, or training to ask me for more information or to share an anecdote of one of their patients. During a workshop one staff member interrupted me; after a particularly powerful video clip she proceeded to thank me and the hospital administration at length for taking the time to provide such a helpful training. I was practically speechless, but it was a truly wonderful moment. She had been inspired by the information and moved to share it.

In training mental health practitioners in U.S. in CBTp, no one has been overly concerned with proving to me that psychodynamic psychotherapy is better than CBTp, though some clinicians have strong beliefs about how to work with people with psychosis that differ vastly from what is person centered, or evidence based, or recovery oriented. But by respecting those beliefs, yet showing them an alternative that works, I have been able to make a difference in the lives of people with psychosis. My own pre-existing beliefs have come to shift in the face of new evidence. There is no such thing as the “perfect CBTp clinician”. The majority of those we train do an extremely good job. And finally no one seems overly concerned about the fact that I speak in a foreign accent and entertain different cultural nuances, in fact some people even seem to like it.

My first CBTp client was a 32-year-old, single, domiciled, unemployed man with a prior psychiatric history that included five hospitalizations. He was first given a diagnosis of schizophrenia at the age of 18 when he was admitted to a local hospital. The hospitalization occurred after the end of a three-year relationship when he discovered his girlfriend cheated on him with a friend. He described the break-up as “traumatizing,” and reported experiencing auditory hallucinations and sensations of people “having sex inside of his body” almost immediately after the breakup. These symptoms persisted with varying degrees of intensity during the years prior to his starting CBTp with me.

The client felt hopeless about his situation, which led to anxiety and depressed mood. He began sessions filled with anxiety and distress. I started treatment using progressive muscle relaxation for stress management, deep breathing exercises to relieve symptoms associated with depression and anxiety, and supportive therapy with a strengths-based approach. Sessions focused on helping him decrease immediate stressors to regain composure and to experience feelings of calm and safety. He made minor progress, but psychotic symptoms persisted.

I consulted with a colleague who recommended I attend a seminar on CBTp. The training session piqued my interest, and I signed up for group supervision. In the beginning, I felt out of my comfort zone, as I imagined trying CBTp in my daily practice, let alone with one my most challenging patients. I attempted CBTp because I felt that I was failing my client, as I was unable to make significant progress in improving my client’s quality of life. I helped him cope with his symptoms but did not explore factors that may have led to his belief that his psychotic symptoms were real. I was unsure how to provide more help to my client.

Because the client and I had a good rapport, we discussed taking a step back from our normal sessions to re-engage with a new approach. I would look at my client’s difficulties from a fresh perspective and treat him as close to a new case as my mind would allow. Nothing I had learned previously was taken for granted; I would elicit the client’s story, build a timeline, retrace the client’s life experiences up to and beyond the point that psychotic symptoms first surfaced. I wanted the client to know that I was invested in him. I took note of the recommendations in the CBTp training that a clinician should be relaxed, open, and familiar for patient engagement to work. It was okay to laugh with clients and disclose something of myself, when appropriate, to build a stronger therapeutic bond. The client appeared interested in a new phase of therapy, and voiced appreciation of my interest in his life. I informed him that we would take this journey together, that many things will be asked of him, that he should be prepared to complete homework assignments, and, if necessary, participate in group treatment. He smiled and agreed, anything to have peace of mind and to stop the distressing body sensations.

I found that building a timeline on paper with the patient to be one of the most simple, yet invaluable tools. It allowed both client and clinician to identify and gain insight into precipitating factors and prior to client’s first psychotic break. As we built the client’s timeline, I expected to go from point A to point B in his history, but it was more like a bouncing ball of memories, jumping among the letters from A to Z. During these sessions I learned the client had two different meaningful relationships end in the same way. The latest was when his girlfriend left him to be with one of his friends. Then he revealed pre-adolescent memories of liking a particular girl in grade school, disclosing how he felt about her, and watching a friend begin courting her the next day. He reported that he still thought about this girl, now a woman. He went on to describe his relationships and his lack of sexual contact with women since his first psychotic break at age 18.

In retrospect, prior to the CBTp training, I had not taken as thorough an inventory of client’s psychosocial history, as I had previously believed. Now, as I sketched his life experiences and asked more probing questions, the client then dropped a bombshell: He reported that when he was four years old, a female teenager sexually molested him, and this continued until he was 13 years old. I was taken aback I had not known this part of his history while working with him for over a year prior to CBTp training. Though sexual abuse history is addressed during any initial contact, a client may not be willing to disclose at that point in time. Later, the client and I focused on current problems; however, until the CBTp training it did not occur to me to circle back and take a more intricate history of causation factors, which in turn, allowed me the opportunity to actually begin treating the client successfully.

Using an outline discussed in the CBTp seminar, I made an initial formulation of my client’s delusions and hallucination in the A-B-C format. (Table 1).

I presented the model to the client, explaining the meaning of each component. The client agreed with my assessment, and we began investigating his belief system. I hoped to find a smidgen of doubt in his present beliefs that would allow me to focus and cultivate an alternative explanation.

Before using CBTp training methods, the client would not acknowledge the possibility that people were not capable of entering his body and having sex. I attempted to normalize his thought process and experiences, noting I would probably feel anxious, depressed, and isolated had I experienced what he did. I praised him for his strength, courage, and resiliency, which further enhanced our therapeutic alliance. He accepted this praise and thanked me for acknowledging his struggles and strengths.

Although the client never completed a journal of alternative explanations for his beliefs, he attended sessions and continued to engage. A further crack in his delusion occurred when we met to formulate an updated treatment plan. As I was typing out his stated goals for treatment, he reported giving “a lot of thought to what we discussed” in our prior session. He acknowledged that he did not know how people could get inside of him, asking aloud, “I don’t know. Maybe it’s a delusion or something?” I had never used the word delusion in any of our sessions, yet it was a part of his vocabulary. I stopped typing and praised the client for his insight. He offered that he believed that the sensation of people having sex inside his body was connected to a girl he liked grade school and to the relationships that had ended “bad” for him. He explained he thought his mind created a male able to have sex with the women because he was unable to experience sexual relations with these women. He said that when he had the body sensations it was as if he were on the outside looking in and he was experiencing what it would be like to have sex with these women.

At this point I was floored, glasses off, jaw open, looking at the client smiling back at me! I praised the client for his insight and for giving thought to our discussion from the prior session. I was elated, yet I wondered if anyone in supervision would believe my report. I doubted that this sort of progress was possible, though I had just witnessed it. At this point the client’s medicating psychiatrist entered the room to check in on him. I asked the client to repeat his conclusions and alternative explanation for his beliefs to his doctor. Both the doctor and I noted a look of relief come over the client’s face as he related how he had come to his conclusions.

What has been described above was accomplished in five sessions, and the client agreed to participate in CBTp group therapy with other patients as a supplement to our individual sessions.

This brief summary cannot accurately describe the discomfort and uncertainty I felt at times during these sessions. It is not easy to overcome self-doubts, yet with trusted supervision, you can take this step. I remembered our CBTp trainer’s statement, “The hardest part of doing CBT for psychosis training is actually believing you can do it.” I can feel my own confidence building, as I attempt to help what I previously termed “a challenging client”.

The journey for a cure is one that is traveled by client and clinician together. The clinician serves as an empathic guide, asking lots of questions along the way, yet in the end, it is the client that discovers his or her cure.

Before taking a position in an adult outpatient clinic in a large public city hospital, I had considered myself a relatively skilled clinical psychologist. The depth and breadth of training I received during my doctoral studies, varied work experiences with people from multiple racial, ethnic, national, and religious backgrounds with a wide array of diagnoses and presenting problems, and clinical supervision from talented and seasoned psychologists, allowed me to feel competent practicing from multiple therapeutic approaches. Despite my training and experience, I was not fully prepared to treat the patients making up the bulk of the caseload that was transferred to me at the clinic—people suffering from chronic psychosis.

My first week on the job I sheepishly asked a colleague how he worked with people with schizophrenia. With frustration in his voice, he responded, “We babysit them.” I was expected only to assess the patients’ risk level, current functioning, and document the same. Thirty minutes once a month was sufficient, and with the burgeoning caseloads of chronically ill patients collected over the years of maintenance and “supportive psychotherapy,” it was a challenge to see patients more frequently. The primary therapeutic goal for most patients who had symptoms of psychosis was to increase their social supports or to begin behavioral activation. When these cases were transferred to me, I kept the goals the same.

My doctoral training in the treatment of psychotic disorders was limited to concrete skills building in short-term inpatient groups, techniques from psychoanalysis and family therapy. The outpatient setting in which I was working and the limitations imposed by a large caseload and managed care eliminated the first two treatment options. Many of my patients had been ostracized by their families or had rejected their families themselves due to their illnesses. So with family therapy off the table, I built rapport and then delicately tried to steer the conversation toward psychotic symptoms. I listened to my patients’ personal understandings of hallucinations or delusions, but did not realize that many of their responses were practiced, rehearsed, and lacking in critical details. I responded to disclosures by validating their emotional experiences without addressing the beliefs directly underlying their psychotic perceptions. Sometimes, I made a psychodynamic interpretation that fell flat or tried techniques from CBT, but they never went anywhere meaningful; I could never get traction. I was taught that contradicting a delusion would strengthen conviction, and I was unsure how to address hallucinations other than to explore the patient’s experience of them. My work with many of these patients felt like a series of fruitless attempts to understand and impact something I was prohibited from directly addressing.

Sitting in the introductory seminar on CBT for psychosis (CBTp), I found myself dismissing the approach as a technique suited for private practice patients with soft psychotic symptoms—people functioning in the space between neurotic and psychotic, who occasionally slipped into delusional thinking. I seriously doubted that it could offer respite for patients who were sick for many years in spite of trials of multiple psychotropic medications and several experienced clinicians. Most of our severely and persistently mentally ill patients were deeply entrenched in their delusional beliefs. Many had been in treatment for years without admitting to positive symptoms of psychosis, leaving it up to collateral information, poor hygiene, negative symptoms, and/or a history of hospitalizations to tip-off providers to the presence of a psychotic disorder. Nevertheless, I listened intently and took on the challenge of identifying a patient with which to try CBTp.

I chose my patient based on his self-reports and a psychiatric history without hospitalizations; he seemed to have mild psychosis non-bizarre delusions. After switching to a CBTp approach, he slowly invited me into his private and confusing world of voices and delusions. He was much sicker than I—or anyone who had treated previously him—had realized. This patient’s disclosures, along with the guidance of my supervisor and peer supervision group, taught me more about the experience of psychosis than I had learned in my doctoral studies. I consequently changed my approach with all patients presenting with psychosis, and my assessment of psychosis has improved, drastically.

I now have an arsenal of knowledge to help me penetrate the wall of impoverished thought and the armor of guarded suspicion that prevents disclosures. A number of my patients have had their diagnoses changed after I knew enough to ask the appropriate questions. For example, one patient had denied auditory hallucinations for the two years he had been treated in our clinic. After altering my approach, he disclosed that a voice repeatedly told him to hide his delusional beliefs or risk death. At the end of the session, he reported his relief to have shared his secret. In addition to knowing what questions to ask, CBTp has taught me the importance of normalizing behavior. Sharing my own brief paranoid ideations has been paramount in reducing the shame which impedes alliance building and maintains guardedness.

I look back at my well-meaning but naïve attempts at therapeutic interventions and see clearly, where I had gone wrong. Social anxieties, phobias, agoraphobia, and compulsions were secondary to paranoid delusions, but I was unaware. One patient with history of “anorexia nervosa,” eventually disclosed that she had stopped eating not because she feared fat, but because she had believed her family was poisoning her. Cognitive and behavioral interventions are quite effective when you are addressing the real presenting problem, and CBTp helped mitigate fears and eliminate safety behaviors based on persecutory beliefs.

The idea of not contradicting a delusion, a common recommendation by clinical supervisors, is more specific than I had initially understood. One must first find the holes in the ideas that uphold the core delusion. It is a matter of identifying the missing pieces, guiding the patient to discover them, and finding room for doubt. The doubt stirs hope and self-interest, and with the first experiences of doubt, the patient begins to engage in the process of therapeutic change.

My job satisfaction since learning CBTp has increased tremendously. My newfound empowerment and hope transfers to those I treat. Even my patients who do not receive CBTp benefit from my increased sense of competence. While I may not be able to use a CBTp protocol with an individual suffering from psychosis, I might be able to introduce doubt, offer a new perspective, help the patient notice that symptoms worsen after life stressors, normalize experiences that previously evoked shame, and help establish sense of connectedness on a genuine level to another person. This is done all within a relatively short period of time with little or no cost to the patient directly. I no longer feel as if I’m spinning my wheels with my patients. I am working, they are working, and therapy is worth our time and efforts.

It was psychosis that drove me into the field of psychotherapy. I decided to become a therapist as a college student while immersed in the arcane writings of Carl Jung, R. D. Laing, and Heinz Kohut. I kept a dream journal, linking my dreams to Jungian archetypes and symbols. During a summer vacation, I briefly entered psychoanalysis, financed by a job as a security guard. My college friends and I abreacted traumas and analyzed each other over Guinness. While other psychology students endured dull classes in abnormal psychology, I happened to sign up for a section taught by George Atwood, an expert on the psychodynamic therapy of psychotic states. Atwood did not speak, in his lectures, about DSM criteria, serotonin imbalances, or reinforcement schedules. Instead, he told gripping stories of his hard-won victories over his patients’ delusions and hallucinations. He spoke of exploring the bizarrely fascinating “subjective worlds” of his patients. In Atwood’s clinical vignettes, he was typically confronted with cryptic and increasingly intolerable delusions—a woman claimed that gangs of murderers were lurking beneath her psychiatric hospital, or a patient who insisted Atwood was zapping her with lasers. At the climactic moment of the story, Atwood suddenly flashed on its symbolic meaning and breached the impasse with a triumphant interpretation. I thought nothing in the world could be more interesting than psychotherapy for schizophrenia. So, with Atwood’s blessing, I embarked on a career as a therapist, hoping to specialize in psychotic states. I completed clinical psychology training in a psychodynamically oriented program and began working in outpatient clinics.

Given my idealized view of psychotherapy for psychosis, it was no surprise that the actual work felt like a let-down. I could not implement the psychodynamic ideas that had entranced me. Many of my patients diagnosed with psychotic conditions sat passively and did not say much. Others deluged me with delusions, but when I tried to interpret these, my perspective was dismissed. With the former group, I learned to help by being gentle, kind, and willing to talk about just about anything. With the latter group, I had success when I directed them away from the psychotic material and focused on concrete goals. Whereas Atwood had portrayed delusions as a royal road to patients’ core therapeutic issues, I began to perceive them as patches of quicksand best avoided. I was most successful with patients with psychosis when I could partner with them to work on something other than the psychosis itself. I counted it among my greatest successes when I was able to motivate a man with pervasive command hallucinations and crippling paranoid delusions to start riding his bicycle again, an activity he had abandoned.

Many of my patients improved in a general way; they became more verbal and more engaged. Yet, there was a lack of vitality in the therapeutic work, as it avoided some of the most emotionally charged aspects of my patients’ inner worlds: their delusions. Moreover, it felt disempowering to work around core psychotic issues rather than to address them directly. When patients spoke about their delusions, I felt helpless. It felt as if the delusions were unmovable blocks looming between my patients and me. When delusions became especially worrisome, I directed patients to the attending psychiatrist for medication adjustment. I felt like a failure when I thought about my studies with Atwood; my cases never seemed to work as had his. I had few triumphant interpretive breakthroughs, and no dissolution of entrenched persecutory delusions. Had my training been deficient? Where could I go for retraining? Was I just not able to work with psychotic states? Was Atwood wrong in claiming that psychotherapy could help with delusions?

CBTp training positioned me to more effectively implement psychodynamic wisdom using practical and easily applied interventions. The protocol offers a clear set of principles and procedures that help me work effectively with psychosis. I can focus on clear tasks in session, such as helping a patient distinguish between a delusion and the activating event, or exploring the logic behind a delusional construal of everyday events.

Prior to CBTp training, I worked for over a year with a 40-year-old woman, “Samantha,” whose children had been removed from her care by child protective services. Samantha avoided visiting them because of a delusion that secret agents followed and harassed her when she left her neighborhood. I used CBTp to “drill down into the A,” the activating events that triggered her delusional belief. I asked Samantha how the agents had most recently showed her they were harassing her. The day before, she explained, a group of agents wearing dark hoodies had blocked her path on the sidewalk. After fine-grained inquiry, it emerged that Samantha had noticed a group of people on the sidewalk wearing dark hoodies; to avoid them she crossed the street, and concluded they were deliberately harassing her. I asked how she could distinguish between a group of people intentionally blocking her versus a group gathering on the sidewalk. She was not sure. She developed doubts; the treatment had traction. I continued gentle questioning and was able to sow enough doubt about her delusion that Samantha was able to leave her neighborhood and visit her children. I have had similar breakthroughs with many patients since training in CBTp. Patients who had seemed closed increasingly disclosed their elaborate delusional creations, and many who appeared stuck revealed delusional obstacles standing between them and their goals. Sometimes, after a few gentle questions, a delusion collapses; other times, the delusion remains unyielding, but even in these cases I get to know the patient more deeply.

In the rapid-stabilization inpatient unit where I work, using individualized CBTp seemed out of the question given the short stay and the acute symptoms of patients. Nevertheless, CBTp training encouraged me to expand my existing approach. Combining the CBT and psychoanalytic object-relations theory was an eye-opening experience that changed my concept of psychosis and provided opportunities to enhance my treatment approach. Object-relations theory helped me to conceptualize the meaning of the psychosis, and CBT helped me develop interventions that addressed specific needs. It helped me in working with K, a 40-year-old woman of Mediterranean descent who immigrated to the United States with her family when she was six years old.

K created a perfect world to protect herself from feelings of being abandoned, lonely, and hopeless. She believed she was the most beautiful woman in the world, the “bride of the creator,” a resident at the “Hilton Plaza Hotel,” and that she would move to Hawaii to meet her godly husband, her son, and daughter. According to K, the devil manipulated people to prevent her from moving. She refused all medication because she believed she had a perfectly healthy mind and body. She had bouts of screaming, demanding to go to the “Hilton Plaza Hotel” or Hawaii. It might take more than half an hour to calm her.

I did not think CBTp could be useful for K because her beliefs were so fixed. She seemed unable to separate the factual world from the fantasy she created. But I soon realized that it was my own lack of confidence that put limits on her possibilities for change. I also thought that the time limitations would prevent treatment with CBTp helping reduce her delusions. Initially, K was unable to be a collaborative investigator, and I was unable to devise a shared goal with her. She did not understand the need for change; it seemed her beliefs were her only reasons and hope to survive daily living. I needed to take the whole process slowly and safely. As I gained confidence, treatment goals evolved. I would: 1) help K distinguish between fantasy and reality by increasing doubts and gathering evidence against her core beliefs and negative self-image; 2) improve her understanding of factors leading to compliance with medications and decreasing the presence of the devil; 3) build coping skills to bring immediate relief.

I tried to understand what her beliefs meant to her, and once I formed a conceptualization of K’s psychosis through a timeline, with marked life events, I began to see how her delusions formed. I discovered that her entire family had abandoned her one-by-one: first her parents passed away, after that her husband and children left due to her mental illness. Subsequently, she had lived in government housing. With great empathy, but with carefully set boundaries, I listened to her story differently. I asked specific questions to identify the meanings of metaphors in her symptoms and the function of the internal objects (persecutory and pleasurable) in her delusional world. We moved forward, slowly, to set meaningful goals for her. While treating K, I observed many different A-B-C sequences (activating event—belief—consequence [emotional\behavioral]) in her thinking, and multiple internal objects brought to life in the psychosis when triggered by daily life events.

K had a large collection of psychological persecutory objects and objects that gave her pleasure and comfort. She believed that medications were poison, slowly killing her, and the hospital staff, manipulated by the devil, harmed her by medicating her. She idealized Hawaii, seeing herself as a flawless, wedding magazine model, the perfect bride of the creator. Anything contrary to these pleasurable images became persecutory objects. K used me as a good object, referring to me as Sophia, her daughter-in-law. I was her immediate relief from distress on the inpatient unit, and as her daughter-in-law, she bound me as a family member, thus reconnecting with her two children, from whom she had been separated by illness.

As treatment progressed and evidence was gathered that contradicted her delusions, doubts increased about her delusions, and K’s core beliefs started to weaken. We had a breakthrough moment: She separated the real world from the fantasy, acknowledging her perfect world Hawaii existed in her spiritual world, and she lived in the factual (ugly) world.

She identified activating events associated with these beliefs, talking to me about how she became overwhelmed with misery and unbearable pain when she looked in the mirror and she saw an ugly, fat, old woman. This poor self-image and low self-esteem kept pushing her to seek something to replace these painful feelings. (I suspect this may have been the starting point of her fantasy world). It seemed this breakthrough session, in which she distinguished the fantasy world from the factual world, was the start of some therapeutic movement.

Soon after the mirror incident, she said she remembered watching two commercials, one for Hawaii and one for the Hilton Plaza Hotel, and reading a magazine, with an ad showing a bride in a white wedding dress. When looking at these images, her feelings of loneliness, guilt, shame, and obsessive thoughts about being abandoned by her family diminished. K identified the joy and happiness she felt at that time. I noticed that her word choices changed. She made a point in saying, “Hawaii is one of the states in the U.S.A.” or of the bridal pictures, “This is me in the spiritual world and here [the inpatient unit] I am K.” “You are my therapist, but in my spiritual world you are my daughter-in-law Sophia.”

K slowly diminished the power of persecutory internal objects and her reliance on pleasurable ones. I was amazed as K began asking other patients about medication. “Do you think medication helps you?”

Still there was resistance: K revealed she believed the devil was in her bed, so that she slept on a bare mattress on the floor, and some nights the devil tried to rape her. Using the free association orientation of psychodynamic therapy, I discovered that she believed her bed looked like a casket and white sheets were, in her mind, a shroud. The “white bed” evoked a memory of a near-death experience she had while delivering her daughter on operating table. I also discovered that she was having recurring dreams about her children and her brother getting arrested and being taken from her. Themes of death and abandonment were presenting themselves. She refused to lie down on this deadly white bed and was afraid to fall. Her dreams reminded her of her separation and the white bed reminded her of her near death experience.

I used humor to increase her doubts, comparing the size of a casket with her current bed (she laughed), and I explained that white sheets were used so that staff could see when sheets need changing, just as was done in expensive hotels. I brought a colorful blanket from sensory modulation materials to cover the bed and gave her pants to wear at night to secure her against the fear of being raped. By creating a sense of warmth, an atmosphere of comfort, and security, K eventually slept on her bed with a white blanket and sheets.

I was surprised that a single word or phrase (example: casket, white sheet) could steer the direction of the work to specific and significant areas of her psychosis. I realized if I properly understood the meaning behind these words and used them in treatment, they would yield therapeutic results. I found constant patterns emerging. If K did not understand something or someone, if it provokes her anxiety, she called it the devil or the devil’s work. My job was to translate these unknown, unexpressed feelings into simple, understandable, explanatory words, and let her find her own peace.

K became aware that her behavior worsened when, triggered by negative thoughts, she became anxious. She understood she needed to use coping skills to distract herself from negative thoughts, and practicing coping skills made her feel empowered.

Psychotherapy played a significant role in a change in her discharge plan. At the time I began to work with K in psychotherapy, she was treatment unresponsive because of persistent delusions and agitated behavior. The plan was for a transfer to a long-term state psychiatric hospital. However, the treatment team did not give up on her, and she improved enough to be discharged to the community residence.

As a creative arts therapist, I employ the creative process to help patients express their motivations, drives, and feelings, and use art forms to provide experiences that help patients explore life incidences that embody their blocks. I use role playing to help patients enact different life situations and to “play around” with alternative experiences. They experience themselves in different ways and witness others through empathy and identification. Since taking the training, I’ve found myself incorporating CBTp theory and object relations theory into my individual psychotherapy sessions as well as my creative arts therapy sessions. Before CBTp, I focused on exploring emotional experiences. Now I explore thoughts and behaviors with an eye on change. I have become more aware of the intricate ways in which thoughts influence behavior. I look at how flexible or limited their choices are when choosing roles to enact, seeing this as a reflection of their world of internal objects. I listen to the specific word choices. I look at the colors and images that they draw during creative arts projects and the pictures they choose for their collages. I listen carefully and actively to them as they talk about their artistic expressions, and then I try to discover the personal meanings for them. I will use this information to find links that I hope will reconnect separated pieces of mental representations of selves into something whole. My therapy approach has become more balanced. I work towards specific “changes” that are rooted in cognitions, and I realize the value of therapeutically driven experiences.

While I was treating patients using CBTp, I followed basic therapeutic principles: 1) develop rapport and trust through active listening; 2) acknowledge the patient’s strengths and instill a sense of hope; 3) assess needs and provide for those needs on a level appropriate to the patient’s level of readiness. These principles were fundamental to developing an alliance in which patients became partners in developing a recovery plan directed at specific goals. With K, I not only tried to maintain a consistently gentle, friendly, respectful, patient-centered approach throughout the treatment period, but I also actively engaged her in small interactions and conversations that became fundamental to the therapeutic alliance. When K was having a particularly hard time, I separated her from the triggers, brought her to a quiet, safe place, listened, acknowledged her frustration, normalized her internal experiences, asked about her immediate needs, and tried to reduce her anxiety. With the accumulation of these small positive encounters, I slowly was able to gain her trust.

Understanding patients’ metaphors of innermost desires was a privilege as a therapist and artist. To help them safely separate from their psychotic experiences and reconnect to their real selves was a constant challenge. Before taking CBTp training I would never have thought that I could treat delusions, but with the guidance at the training sessions I became a more effective therapist, finding better ways to help my patients so they can change.

Several aspects of training in CBT for psychosis improved my understanding of psychosis; it also provided me with a new set of skills to help patients explore their perceptions, and gave me the psychodynamic framework guides in making sense of the psychological meaning of psychosis. But as a supervisor charged with nurturing learning in trainees, one of the most important aspects of CBTp training is to create an ambition to treat challenging patients, and instilling the belief that the therapist can make changes in the lives of patients who, in a lot of ways, have been perceived as chronically ill with fixed false beliefs and beyond help.

In this case CBTp training helped increase my ambition to help a particular patient make sense of his psychological conflicts and psychotic phenomenon. D, a 35-year-old man of Native American descent, was referred to me after a car accident in which he was the driver. He was so disorganized in his thoughts and behavior that the police decided to send him to a psychiatric emergency room instead of giving him a summons. He was hospitalized and was started on an antipsychotic medication (perphenazine with no significant side effects and marginal improvement in his psychotic symptoms). Negative symptoms predominated, and in sessions he spoke with long speech latencies, had a blunted affect, and showed a poverty of thought. Our sessions often had silent periods, while I waited for him to answer questions or to express himself. He was always calm, polite, and soft-spoken, but guarded. His thought disorder left me feeling hopeless about being able to help him very much.

D had, in the past, been passionate about driving. In the initial phase of our work, he had been training to become a school bus driver, but he had struggled throughout his training, had problems following the instructions, had difficulty communicating with others, and eventually was asked to discontinue the training. He then became a taxi driver. Given his disorganized thought processes and cognitive impairment, I was quite surprised that he had such a good sense of direction. Often times he was unable to tell me of the names of places he had visited, but he was able to give me the street addresses and locations.

Training in CBT for psychosis encouraged attention to the timelines of the psychological experiences of patients, with early experiences frequently providing insight into psychological meaning. D began to experience psychiatric symptoms approximately five years before our meeting, when he was first hospitalized. He was unable to provide details, except to say he began to hear voices. He was always reluctant to talk about the voices, often saying it had been a long time ago and he could not remember. After the first psychiatric admission, he lost his job; shortly after, his wife left him. With no job and no money, he moved to New York to live with his cousin and family. He resided in a basement and chose to drive his taxi cab at nights so that he would not have to interact with his cousin and his family much. D could not explain the causes of the tension between him and his cousin.

Initially D often missed appointments, explaining that his late night work left him tired; he sometimes simply forgot the appointment. With the ambition from the CBTp training, I tried engaging him more; he slowly began to share his life before illness. He was very proud of his previous work in the Phoenix airport as a driver who often worked at night; he shared nostalgic feelings about his personal life and work life. I gently explored the possible connection of his current commitment to driving at night and his dream of getting a job at John F. Kennedy (JFK) airport, and his strong nostalgic feeling for the past. He confessed he had never thought of it that way.

After I made this emotional connection for him, he was more open about his past and his voice-hearing experiences. He revealed that he most often heard an unfamiliar male voice insulting him for moving to New York. It was the first time that I saw genuine emotional pain in him. Once he became conscious that his current goal of working at the airport was modeled after his past experience, he was able to set clear, realistic goals. He was more determined to work and save money so that he might eventually own his own taxi cab. Although he still hoped to work at an airport, he was less anxious about not having achieved this goal.

He described his former life in Phoenix as “paradise lost.” Once he had named his nostalgia this way he was able to talk about how much he missed his former life. What I had thought earlier in his treatment were negative symptoms of flat affect and poverty of thought, now appeared to reflect the passivity of his despair and his inability to grieve his former life. He began to share his thoughts more easily and with emotion. He hoped to move out of his cousin’s basement once he was more financially stable. And he adhered to taking his medication, which helped to organize his thinking.

I work predominantly with a Haitian population, providing outpatient group and individual therapy. I speak Creole, as do many of my patients, whose primary language is Haitian Creole; many embrace supernatural cultural beliefs, and present with a wide range of psychiatric conditions. However, within the Haitian population, psychotherapy is a foreign concept, illnesses are commonly viewed to be caused by external factors, and mental illness often is attributed to supernatural forces, mainly as a consequence of Vodou spells. These beliefs can be quite challenging to the therapeutic process, and because they are deeply embedded cultural norms, they can be a major barrier to effective treatment. The therapeutic process becomes more challenging as patients’ symptoms become more acute—essentially, the more severely psychotic, the more it is attributed to Vodou spells and other external forces.

I often struggled with finding the right therapeutic model that would address and normalize the patients’ cultural beliefs, as well as effectively target the psychosis. My initial focus in treatment had been on normalizing the process and helping patients find more effective ways to cope with their symptoms while providing support. My instinct was to explore specific beliefs. If a patient believes his mental illness to be Vodou related, I might “go on a fishing” expedition: What has he done to address the beliefs that the mental illness is Vodou related? Has he visited a Ougan (Vodou priest) prior to accessing mental health services? What supporting evidence do they have for their beliefs? I’ve found that most of my patients have already consulted a Ougan prior to entering treatment. Often times the Ougan’s prognosis has far-reaching impacts on treatment. For example, if the Ougan has impressed upon the patient that his/her psychiatric symptoms are a manifestation of Vodou spells, then the opinions/suggestions/advice of this culturally credible source would further support the patient in his/her already firmly held cultural belief that his/her mental illness is Vodou related and therefore not treatable by psychotropic medications and talk therapy.

My most recent patient, a 35-year-old woman with a long psychiatric history of schizophrenia, had chronic auditory hallucinations, from which she experienced much distress. However, the most agonizing thing for her was internal conflict of beliefs, and though she had been in treatment for many years, her concern remained: Were the voices Vodou related or the result of mental illness? The patient revealed that when she first became sick in Haiti she was brought to see a Ougan, who confirmed her symptoms were caused by a Vodou spell. The Ougan visit was 15 years earlier, yet the patient remained preoccupied with the belief in a Vodou spell, despite mounting evidence to the contrary. Medications and therapy were directly linked to a decrease in her positive symptoms and an increase in her focus/concentration, coping skills, and overall general functioning in the community.

I often conceptualize and pull from varying theories, philosophies, and techniques/interventions depending on my patient’s presentation, treatment goals, and my own judgment of what would be most clinically sound and effective. I have used CBT concepts and techniques in treating patients over the years; however, I still struggled with how to best reach my patients who experienced psychosis as Vodou related. It was not until I learned about CBTp that I had an “aha!” moment. I had a sense of renewed hope in the treatment process of working with such challenging beliefs.

With CBTp I was given tools to guide my patients toward recovery. It has allowed space for the CBTp technique of normalizing the experiences of my patients in an authentic way, in which their psychosis and/or internalization of being a “moun fou” (crazy person) is significantly reduced. This model also allowed me to be nonjudgmental during the treatment process by fostering the creation of a safe space for true connection with my patients. In the role of therapist, I am viewed as a co-investigator of the complexity of the patients’ inner world and perceived reality rather than an expert. With the use of mindful self-disclosure, I have become a real person to my patients—with perceptual experiences that are on a continuum of the range of possible human experiences. For a population in which therapy is foreign, this causal way of working helps strengthen our therapeutic alliance, which is key in the recovery process.

In a CBTp framework patients’ experiences are depathologized, and the therapist guides, connects with and shares in the patients’ explorations, reframes, and reconstructs understandings from a nonjudgmental space. The step-by-step process and guided questions helped my patients come to their own conclusions as they wrestle with making sense of the gaps and discrepancies in their narratives. My patients have learned to develop self-awareness, name their cognitive distortions, and change their narratives and understanding when there is limited or no supporting evidence for previously held beliefs. In mapping a visual timeline of the events in my patients’ lives, they and I are able to see patterns of pain, loss, and devastation that may have contributed to presenting symptoms of psychosis.

The CBT for psychosis model is about developing an alliance with my patients in which they are empowered to share stories—punctuated with messy, stressful life events and experiences—and have a safe space to explore and reconstruct adaptive narratives that lead to more fully functioning lives. The techniques espoused by CBTp allow a better understanding of the metaphorical, complex world of my patients that goes beyond superficial presentations. I am able to work with presenting challenging material in gentle and sensitive ways, which helps soften the resistance so many of my patients have as they enter treatment and struggle with stigma, shame, and palpable, agonizing internal conflict.

I was introduced to cognitive-behavioral therapy for psychosis (CBTp) as a clinical psychology graduate student completing a track in the treatment of severe mental illness. Many of my instructors had extensive careers providing clinical care in community mental health clinics and public hospitals. The majority depicted CBTp as a novel approach with little impact on psychotic symptom reduction. This view was informed by a divide between psychoanalytic and cognitive behavioral orientations within the program. In fact, this paradigm reflected a partisan-like division between theoretical positions that foreclosed critical discourse between newly emerging research on cognitive-behavioral practices and longstanding beliefs about what kind of therapy could be done with psychotic patients. My clinical identity formed across these divergent terrains, limiting my ability to integrate these perspectives. My analytic interests seemed incompatible with my desire to work with patients experiencing psychotic symptoms.

The treatment of psychosis, as illustrated during much of my training, included psychopharmacological interventions and various forms of brief psychodynamic-oriented or supportive psychotherapy. Didactics linked medication management with brief behavioral activation strategies and/or psychosocial groups, all valuable efforts in the provision of services and increasing skills and social support for patients. However, lectures highlighted beliefs regarding the intractability of symptoms, purporting the typical trope: treatment-resistant. I was unclear about my role as a psychologist in this mélange of services, and started to doubt how much could be accomplished in individual therapy with these patients.

I attended an intensive clinical intervention course focused on the treatment of psychosis. The instructor introduced the primary tenets of a cognitive-behavioral treatment. My professor introduced the notion that cognitions exist on a spectrum, with varying degrees of conviction, some more amenable to change than others. I was intrigued.

In addition, I began to work closely with a cognitive-behavioral supervisor who had a psychodynamic background. He bridged conceptual language with application, providing a lens with which to consider alternative and active approaches to clinical work. Modeling a genuinely collaborative style, we problem-solved and applied change-based strategies. We engaged in a learning process that helped me become more aware of the relationships between affect, trauma, and psychosis. With this, I could hope more for the patient and be ambitious about the progress that could be accomplished.

During my final year of training, I worked with a homeless man who reported auditory hallucinations. Treatment oscillated between making meaning of his experiences and increasing his ability to cope. Progress was slow; at times, I felt confused and unsure of the direction of this therapy. My supervisor encouraged me to be an active collaborator while listening deeply for affective dynamics. With this stance, the patient was better able to regulate his emotions and behavior.

With regard to CBTp versus psychodynamic approaches, there is no need to choose. As a certified dialectical behavioral therapy (DBT) clinician and trainer, I have learned that there is a broad flow of “both/and,” not a narrow channel of “either/or” in any treatment. From this vantage point, the task is integrating CBT strategies and psychodynamic approaches to make meaning of a patient’s symptomatology. My current work focuses on individuals with psychotic symptoms and/or borderline personality disorder. With the support of an interdisciplinary team and a weekly CBTp seminar, I have been able to further integrate psychodynamic case formulations with directive treatment strategies.

This blending of models has helped many of my patients experience symptom relief through learning that their beliefs exist on a continuum; these individuals benefit from the “shared investigations” and queries we pursue related to their experiences. Monitoring the patient’s level of distress helps identify activating stressors and the varying beliefs that develop in relation to trauma and life events. Patients teach concepts back to me. Shared learning helps to build self-efficacy and increase hope.

For example, a female patient in her 50s presented for outpatient treatment after being discharged from the hospital. Once stabilized, she began to share her beliefs that she made “horrible things” happen to other people, most significantly on 9/11 when she drove to work in a two-toned colored car wearing an outfit comprised of the same two colors. Through her two-toned choices, people were now split into two groups—“the good and the bad.” She reported that on 9/11 the “bad” people bombed the Twin Towers hurting all those who were “good.” Subsequently, she lost her job and her apartment. She became severely depressed and believed that men were following her, wanted to hurt her, and were waiting for her to make another “mistake.”

During one session, the patient stated, “My thoughts are really messed up, aren’t they?”—demonstrating an ability to evaluate and question her beliefs about causing mass destruction. We investigated these beliefs without judgment, moving towards a mutual conclusion that sometimes her mind had difficulty separating her beliefs about herself and the world from external circumstances. She agreed to monitor her thinking by completing thought logs throughout the week. Over time, she came to learn how to question the veracity of her beliefs and the strength of her convictions by gently reminding herself that thoughts are not facts, nor are feelings immutable. She sought evidence in her environment, which also emphasized her tendency for self-blame. We came to understand that the depth of her shame and self-hatred were connected to her despair. We also came to learn more about how these “beliefs of self” related to past traumas and emotional neglect across generations.

Blending psychodynamic theory and CBTp provides thoughtful, accessible language with which to frame treatment and employ clinical interventions. I have witnessed patients’ level of distress reduced. Their ability to connect life stressors and past trauma to emotions and cognitions has been essential in gaining understanding and control over their lives.

Working in an environment that supports integrated clinical work, I am better able to provide individualized treatment driven by evidence-based practices. Cognitive and behavioral components that emphasize collaborative learning and shared investigation are necessary for change. These techniques, along with my psychodynamic lens are critical in maintaining hope and an expanding vision for clinical work that moves beyond the stagnant trope of “treatment resistant.”