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CBT for Psychosis: A Symptom-Based Approach

by Roger Hagen,, Douglas Turkington,, Torkil Berge,, and Rolf W. Grawe. New York, Routledge, 2010, 296 pp., $31.95.

Reviewed by Abby Snavely, M.D.; Cheryl Chessick, M.D.
Am J Psychiatry 2011;168:1226-1227. doi:10.1176/appi.ajp.2011.11050682
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Dr. Snavely reports no financial relationships with commercial interests. Dr. Chessick has received funding for clinical trials from Dainippon Sumitono Pharma, Novartis, and Wyeth.

Book review accepted for publication May 2011.

Accepted May , 2011.

Copyright © American Psychiatric Association

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This ultimately hopeful book contains far more than its title suggests. In 17 wide-ranging chapters, international experts write about theory, treatments, and research concerning the psychological understanding of psychosis. As is commonly experienced in such collections, this volume has frequent shifts in tone and focus, with occasional repetition or contradiction. Some chapters contain cognitive-behavioral therapy (CBT) in a perfunctory way, or not at all. The case studies are illustrative, though not intended to be instructive. One would need to look elsewhere for a practical treatment approach. Nonetheless, in summary, it is an often illuminating and thought-provoking book.

The book is divided into four broad parts, beginning with a section on cognitive models of psychosis and their assessment. Chapter 1 carries the same title as the book itself and provides an overview of CBT and CBT for psychosis, setting the stage for a dimensional and psychological view of psychosis. Here, two of the editors, Hagen and Turkington, present a concise and logical rationale for treating psychotic symptoms as experiences rather than simply as items that meet diagnostic criteria for a specific disorder. A primary assumption of this model is that psychotic symptoms lie along a continuum of normality. The authors outline key factors in CBT for psychosis, expanded on throughout the book, including rapport building, education, normalization, case formulation, and relapse prevention.

Chapters 2 and 3 look at cognitive models of auditory hallucinations and delusions. Again, these symptoms are emphasized as being part of a spectrum of common human experience not necessarily associated with psychosis. Hallucinations are identified as “misattributed cognitions,” while several cognitive models for delusions are presented. Chapter 4 details various symptom measures and basic strategies for the assessment of psychosis.

Part II focuses on the practice of CBT for psychosis. Common factors in psychotherapy are reviewed in Chapter 5. Here, the authors helpfully relate their own experiences to instruct the reader in forming an alliance with patients with psychosis. Chapter 6 highlights the commonality of psychosis as a justification for the use of normalization as a key component of CBT for psychosis. The important topic of early intervention is reviewed in Chapter 7, with an overview of the limited research supporting CBT in prepsychotic or first-episode patients. The treatment outline provided differs little from that for CBT for other psychotic populations, including the focus on individual experiences and meanings (here, often developmental issues). Chapter 8 examines command hallucinations and presents an outline of a manualized cognitive treatment for this distressing symptom, with a corresponding case study. In a remarkably intriguing and complete Chapter 9, Stolar and Grant propose a cognitive model and treatment strategy for negative symptoms and thought disorder, for which pharmacotherapy has limited benefit. They propose that these symptoms arise in part from low expectations of success and pleasure. The negative attitudes, stress of interaction, and limited activity can be addressed by cognitive behavioral techniques. Chapter 10 shifts the focus to relapse prevention and emotional recovery. After mounting evidence and support for the CBT models and their efficacy in a variety of psychotic symptoms and different populations, the final chapter of this section (Chapter 11) discusses barriers to implementation of CBT for psychosis, with a focus on North America.

Part III concentrates on conditions that commonly co-occur with psychotic symptoms. Both theoretical and clinical aspects of the evolving understanding of the relationship between trauma and psychosis are expertly written about in Chapter 13. The authors encourage us to sensitively inquire about trauma in our patients with psychosis to enhance understanding. They use case studies to show how trauma-focused CBT can help alleviate distress associated with psychotic symptoms. Chapter 12 (substance misuse) and Chapter 14 (family treatments) provide good overviews of general approaches, though without specific mention of CBT. Chapter 15 looks at psychological interventions to improve work outcomes, including one CBT approach.

Finally, Part IV gives attention to bipolar disorders, based on the idea that these may exist on a continuum of psychotic disorders. Chapter 16 begins with a discussion of bipolar symptoms in psychological terms and ultimately presents an integrated biopsychosocial model to understand these illnesses. The final chapter of the book provides cognitive models of bipolar disorder and evidence supporting their use in treatment.

This book provides a compelling case for a psychological view of psychosis that can influence current treatments and future research. I suspect that many of these ideas will be new to mental health professionals in the United States. The chapters need not be read in succession or in total, as many provide a succinct overview that can stand alone. Though lacking in cohesion, this book offers a considerable breadth of information that could be useful for both clinicians and researchers.




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