Academic journal article Hong Kong Journal of Psychiatry

Cognitive-Behavioural Therapy of Psychosis: An Overview and 3 Case Studies from Hong Kong

Academic journal article Hong Kong Journal of Psychiatry

Cognitive-Behavioural Therapy of Psychosis: An Overview and 3 Case Studies from Hong Kong

Article excerpt


This article reviews the current evidence regarding cognitive-behavioural therapy for psychosis. There is promising evidence that cognitive-behavioural therapy is an effective treatment option in reducing psychotic symptoms in medication-resistant schizophrenia. However, there is less evidence for its effectiveness in first-episode psychosis. Three case studies are presented to illustrate some of the techniques that could be applied to cognitive-behavioural therapy for psychosis in Hong Kong Chinese psychotic patients. We conclude that more rigorous local research in this field is urgently needed before its widespread adoption in Hong Kong.

Key words: Cognitive therapy; Hong Kong; Psychotic disorders, Schizophrenia, Case report


Psychoanalysis was used as the mainstay of treatment of schizophrenia in asylum patients, until the 1950s, when a sudden change in the prevailing attitude about the treatment of schizophrenia saw the introduction of electro-convulsive therapy and chlorpromazine into clinical practice. The biological predominance in the treatment of schizophrenia was consolidated with the results of the Boston Psychotherapy Study, which contrasted 2 forms of psychotherapy--supportive and investigative--and found no advantage for either. (1)

However, during the past decade, there has been a resurgence of interest in the psychological management of schizophrenia. Some treatment strategies aim to reduce distress or intensity of resistant psychotic symptoms (cognitive-behavioural treatment), while others focus on relapse prevention (family intervention, personal therapy). In a recent meta-analysis of 106 studies, psychosocial treatment of schizophrenia had an effect size of 0.39 [95% confidence interval, 0.32 to 0.44], meaning that a typical patient in the experimental group was better off than 65% of control patients. (2) Control patients in the meta-analysis were those not receiving any psychosocial intervention. Relapse frequencies were also 20% lower for patients who received psychosocial treatment in addition to standard treatment compared with standard treatment alone.

Cognitive Therapy for Psychosis

Collaborative Empiricism

Beck reported use of cognitive strategies in challenging beliefs in his deluded patients in the 1950s,3 however, this was not pursued as his mainstream interest. It was not until recently that interest revived in the use of cognitive-behavioural strategies in the treatment of psychosis. According to Alford and Beck, cognitive therapy for delusion is similar to cognitive therapy for depressive disorders in emphasising collaborative empiricism and development of therapist-patient trusting relationship. (4) They also discussed the importance of challenging the validity of delusional beliefs and behavioural experiments.

Challenging of Delusions

Lowe and Chadwick used belief modification and reality testing to challenge delusions. (5) Belief modification and reality testing involve helping patients to sensitively question the evidence underlying their beliefs and to set up behavioural experiments to test the reality of the evidence for their beliefs. Socratic questioning is used to gather contradictory evidence. This technique has to be used in a collaborative relationship as confrontation per se increases conviction in delusional beliefs. (6)

Normalisation Strategy

Kingdon and Turkington (7) argued that, as psychotic symptoms could be found in healthy persons (8) and psychotic symptoms could be induced in healthy people in states of sensory deprivation, normalising techniques could be employed to reduce the sense of helplessness and stigmatisation in psychotic patients. Fowler et al also advocate such a normalising approach. (9) Reducing hopelessness and demoralisation is important as both have been found to be associated with suicidal attempts in patients suffering from schizophrenia. …

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