Cognitive, Emotional, and Social Processes in Psychosis: Refining Cognitive
Behavioral Therapy for Persistent Positive Symptoms
Elizabeth Kuipers1,2, Philippa Garety2, David Fowler3,
Daniel Freeman2, Graham Dunn4, and Paul Bebbington5
2King’s College London, Institute of Psychiatry, Department of
Psychology, PO Box 77, London SE5 8AF, UK;3School of Med-
icine, Health Policy and Practice, University of East Anglia, UK;
4Biostatistics Group, Division of Epidemiology and Health
Sciences, University of Manchester, UK;5Department of Mental
Health Sciences, UCL, University of London, UK
Psychosis used to be thought of as essentially a biological
condition unamenableto psychologicalinterventions.How-
ever, more recent research has shown that positive symp-
toms such as delusions and hallucinations are on
a continuum with normality and therefore might also be
susceptible to adaptations of the cognitive behavioral ther-
apies found useful for anxiety and depression. In the con-
in psychosis, the latest evidence for the putative psycholog-
ical mechanisms that elicit and maintain symptoms is
reviewed. There is now good support for emotional pro-
cesses in psychosis, for the role of cognitive processes
including reasoning biases, for the central role of
appraisal, and for the effects of the social environment, in-
cluding stress and trauma. We have also used virtual envi-
ronments to test our hypotheses. These developments have
improved our understanding of symptom dimensions such
as distress and conviction and also provide a rationale
for interventions, which have some evidence of efficacy.
Therapeutic approaches are described as follows: a collab-
orative therapeutic relationship,managingdysphoria,help-
ing service users reappraise their beliefs to reduce distress,
working on negative schemas, managing and reducing
ing biases by using disconfirmation strategies, and consid-
ering the full range of evidence in order to reduce high
conviction. Theoretical ideas supported by experimental
evidence can inform the development of cognitive behavior
therapy for persistent positive symptoms of psychosis.
Key words: schizophrenia/model/continuum/
As an inpatient, I was in a psychiatric ward for people who
seemed worn out by life. I was entertaining competing the-
ories of why I was there. A part of me was aware that other
people saw me as mentally ill and that I had become a social
Schizophrenia and related psychotic disorders create
enormous burdens for individuals who suffer from
them, for their carers, for the mental health services,
and for society at large.2People with psychosis have
always endured very poor social outcomes, including
80% unemployment rates.3,4Even worse, they have
been stigmatized and misunderstood. The lifetime risk
of committing suicide is 5%5with up to 13% showing
moderate to severe suicidal behavior in a recent study.6
For most of the 20th century, scientific explanations
of schizophrenia emphasized its otherness. The state-
ments and experiences of people with the disorder were
regarded as quintessentially incomprehensible.7,8Such
phrenia as a distinct and distinguishable category and
the postulation of a discreet biological causation. It
also led to a focus on biological treatment at the expense
of psychological interventions. Partly as a consequence,
the symptoms of psychosis were seen primarily as the
building blocks of diagnosis, rather than having an inter-
esting and meaningful content.
Toward the end of the 20th century, it became increas-
ingly apparent that the focus on biological mechanisms
and treatment was restricting the possibilities of amelio-
rating the condition. Medication remains the first line of
treatment. However, it is far from wholly effective, not
only because 50% of people do not take their prescrip-
tions reliably.9Many patients remain treatment resistant
despite adequate doses of antipsychotic drugs, and side
effects may impair consistent and optimal treatment.10,11
Persistent positive symptoms such as hallucinations and
delusions can be severely distressing and disruptive of
The ineffectiveness of intensive psychotherapy (which
sometimes makes outcomes worse12) also contributed
to an increasing pessimism. However, the 1990s saw the
emergence of a paradigm shift, brought about by the
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Schizophrenia Bulletin vol. 32 no. S1 pp. S24–S31, 2006
Advance Access publication on August 2, 2006
user movement,1new ideas about recovery,13and
renewed interest in psychological treatments. Some years
ago, we proposed a social and cognitive model of psycho-
sis (figure 1) as a way of summarizing what was known
and, hopefully, of guiding new research.14Since then,
a considerable amount of research has illuminated social
and psychological mechanisms in psychosis. Related to
this has been increasing support for a view of psychosis
findings have between them begun a process of normali-
zation, whereby psychotic experience is seen as less
strange and more understandable. In this article, we
use our model as an organizing principle to describe
this new research.
A Cognitive Model of Psychosis14
bination of factors that shape and maintain positive
symptoms such as delusions and hallucinations. It incor-
porates the continuity of psychotic and nonpsychotic
experiences and the idea of a biopsychosocial vulnerabil-
ity which can be triggered by events. We posit that
appraisal plays a central role in that it is not un-
usual experiences per se but a person’s appraisal of
changes and low self-esteem are particularly important.
We have also tried to incorporate findings that relate
to adverse social environments. Unlike Broome et al,15
we do not specify biological explanations, although these
are implicit. We emphasize, as one route to symptom
development, the importance of cognitive dysfunction
such as information processing deficits which can lead
to anomalous experiences. In contrast to Morrison
et al,16we see this as distinguishing between psychosis
and disorders such as anxiety or depression. Further,
we suggest that reasoning biases play a particular role
in symptom formation and their subsequent mainte-
nance. Our research group have been able to test some
of the putative pathways in our model, as indeed
have other researchers. The most recent results are
Studies of Psychosis As a Continuum—A Biopsychosocial
One of the consequences of moving away from a rigid
categorical view of the symptoms of schizophrenia is
that it reconfigures the problem of the threshold for rec-
of various criteria. In the late 1980s, evidence began to
accumulate that the experiences described by patients,
such as feelings of paranoia and hearing voices, were
not confined to clinical groups. Bentall et al17showed
that up to 25% of the normal population experienced
hallucinations at least once, and Tien et al18in the gen-
eral population found an annual incidence of 4–5%
for hallucinations. Johns et al19showed that up to 4%
of individuals in a population survey had these ex-
periences. Freeman et al20have recently found that up
to 30% of a nonclinical population have paranoid
ideas. P. E. Bebbington, D. Freeman, C. Steel, J. Coid,
(unpublished data, 2006) have confirmed in a large popu-
This overlap between clinical and nonclinical groups
has been confirmed in other studies. Romme21was one
of the first to publish in this area, with a study of voice
hearers, 30% of whom experienced voices. In this group,
the distinguishing feature of those in contact with mental
health services was their level of distress. Davis et al22
compared people with psychosis with evangelical Chris-
tian groups. The main difference was not their experience
of voices but in the fact that the evangelical group felt
more positive about them, while the clinical groups
were more distressed. Similarly, Peters et al23found
that when members of new religious movements such
as Hare Krishna or Druids were compared with patients
psychosis and ‘‘normals’’ were quantitative rather than
qualitative and that distress contributed to patient status.
ical rather than nonclinical groups and was much more
likely to bring people to clinical services.
reasoning & attributions
appraisal of psychosis
Appraisal influenced by
Reasoning & attributional
Dysfunctional schemas of
self & world
Isolation & adverse
Fig. 1. A Cognitive Model of the Positive Symptoms of
Psychosis (As Discussed in Garety et al).14
Cognitive, Emotional, and Social Processes in Psychosis
Research Into Individual Symptoms and
Since the 1980s, Richard Bentall has maintained that
schizophrenia is a ‘‘failed category’’ in terms of being
able to predict specific treatment or outcomes consis-
tently.26He has argued for ‘‘single symptom’’ research
into delusions or hallucinations instead of research
into schizophrenia as a whole. This argument has been
persuasive, and much psychological research has con-
centrated on developing a clearer understanding of
delusions,27paranoia,28and hallucinations.29This has
allowed a clearer focus on the dimensions of individual
symptoms, such as distress, conviction, and preoccupa-
tion, andhasledtomoretargetedpsychological interven-
have also raised doubts about the utility of separate
categories of schizophrenia and bipolar disorder.31
Emotional Changes in Psychosis
A diagnosis of schizophrenia has tended to discount the
considerable amount of emotional disorder associated
with it, in a manner that can also inform psychological
treatment options. For instance, depression is often asso-
ciated with schizophrenia, such that up to 40% of people
with the latter also have clinical levels of depression,32,33
accompanying low levels of self-esteem,34and a high
evidence of obsessional compulsive disorder,3740% have
a dual diagnosis of comorbid substance misuse,38and
the development of psychotic symptoms.
Our group is particularly interested in the impact of
emotional changes on symptom formation and mainte-
nance. Using a new version of a schema questionnaire,41
we have found that the positive symptoms of psychosis,
delusions and hallucinations, are associated with extreme
negative evaluations of the self and others.42In corrob-
oration of this possible pathway, Barrowclough et al43
found that low self-esteem in patients was associated
with negative evaluations (criticism) by carers and higher
symptoms. Similarly, Krabbendam et al44have shown
that depression contributes to the later development
in delusions in people with preexisting anomalies of
experience. Myin-Germeys and colleagues45demon-
strated that fluctuations in positive symptoms of psycho-
sis are associated with time-sampled changes in negative
The Central Role of Appraisal
Birchwood33has found that appraisals of auditory hallu-
cinations as powerful and controlling are linked to de-
pressed mood. We have also found this for persecutory
delusions.46Further, negative appraisals of symptoms,
of self and of others relate to suicidal ideation and high
alcohol intake.47Morrison et al16showed that, like
people with phobic disorders, individuals with psychosis
exhibit safety behaviors. We have recently confirmed
this and have shown that they relate specifically to delu-
sional persistence.48,49Along with other investigators,
we have also looked at illness appraisals, using methods
developed in health psychology. Lobban and colleagues
and that patients make similar appraisals in both phys-
ical and mental health conditions. We also found that
negative illness appraisals of psychosis were associated
Cognitive Processes: Reasoning and Attributional Biases
The importance of reasoning biases in psychosis has been
confirmed by recent research. Many of us hold with con-
viction ideas that do not have much basis in evidence, for
instance, beliefs in astrology, alien beings, telepathy, or
ghosts. A quarter of us act on the basis of beliefs in
our star signs. Further, once we hold a strong belief, it
is normal for us not to consider alternatives impartially,
the so-called ‘‘confirmatory bias.’’ For those with psy-
chosis, it has been found that in addition to these normal
biases, they tend to use less evidence before making a
decision, the ‘‘jumping to conclusions’’ (JTC) reasoning
bias,27which has particular relevance for delusional
thinking. Wehave found that reasoning biases contribute
differentially to delusional symptom dimensions, specif-
ically to conviction.52In sample of 100 patients with psy-
chosis, 50% showed a JTC reasoning bias, and this
contributed to delusional conviction, whereas disturbed
affect was linked to delusional distress.
JTC is found both in people with delusions and also
in those in recovery from delusions.53Further, JTC is re-
lated to belief inflexibility and to an inability to generate
alternative explanations for experiences.54
Bentall and colleagues55have also found evidence of
‘‘attributional biases,’’ although this is now less well sup-
ported.56In particular, some people with persecutory
delusions have an ‘‘externalizing bias,’’ being more likely
to attribute blame for negative events to external factors,
particularly to other people. This contrasts markedly
with the self-blame of people with depression.
Anotherelegant setofexperimentssupports theideaof
‘‘self-monitoring problems’’ in psychosis,57,58which can
lead to hallucinations or delusions of control.19,59There
is also evidence for what Hemsley has called ‘‘disruption
to a sense of self’’60,61in that poor use of contextual in-
formation can disrupt the ability to process ongoing
experiences.62Kapur63,64has recently argued that abnor-
malities of dopaminergic activity are related to our un-
derstanding of the salience of experiences, and an
E. Kuipers et al.
excess may form one of the routes to ideas of reference
in acute episodes.
We also know that people with psychosis have well-
established ‘‘cognitive deficits’’ in attention and working
memory.65These are factors to bear in mind while offer-
ing interventions but may also contribute to symptom
of individuals claiming to have experienced alien abduc-
tion found that these experiences were related both to
a high rate of sleep paralysis and to false recall and
Psychosis and the Social Environment: Triggering and
A recent study reported that supportive social environ-
ments are associated with reduced positive symptoms
of psychosis and that family support relates particularly
to reduced hospital admissions up to 3 years after a first
episode.67Aspects of adverse family environment can be
tapped by the expressed emotion measure, which is well
established as a predictor of relapse.68We have recently
found that high levels of expressed emotion in carers re-
late to negative affect. In particular, in patients with a
recent relapse of psychosis, criticism on the part of
carers predicted anxiety but not more severe psychotic
It is becoming increasingly acknowledged that high
rates of trauma and adversity occur before the onset of
psychosis, often years before.70–72These studies confirm
that bullying and sexual abuse are associated with nega-
tive self and other schemas and with positive symptoms
such as persecutory delusions and hallucinations. There
may be a particular relationship with hallucinations, al-
though direct links between trauma and hallucinatory
content were relatively rare.73Recent studies have shown
links between specific attributes of recent events and the
content of delusions and hallucinations in a first episode
Wehavehypothesizedthat traumaand adversityaffect
both information and emotional processing, leading to
intrusions which are then misinterpreted and appraised
as symptoms of psychosis.41,75
Virtual Reality Studies
Alongside the above studies, we have developed novel
virtual reality paradigms in collaboration with Professor
Mel Slater at University College London, UK. It is pos-
sible to immerse people in a virtual reality ‘‘cave’’ such
peopled with avatars (computer generated human figures
that provoke emotional reactions in people in the same
way that cartoons do). Within these environments (a
library scene and an underground tube train), we have
been able to show that nonclinical individuals may de-
velop persecutory thoughts about avatars: eg, ‘‘they
were telling me to go away.76’’ Anomalous experiences
differentiated in normal samples between individuals
who were just anxious and those who had persecutory
that such thinking is on a continuum, as predicted from
earlier studies. We plan to extend this work into clinical
samples with the intention that it will inform treatment
Therapeutic Approaches in Cognitive Behavior Therapy
(CBT) for Positive Symptoms of Psychosis
The first description of a cognitive behavioral approach
to delusional ideas was provided by Beck,78who dis-
cussed his client’s persecutory ideas in a case study. How-
ever, Beck did not pursue cognitive research in psychosis
at that time, and the next reports were of case studies and
uncontrolled studies in the 1970s and 1980s. The main
evidence for CBT for psychosis comes from the United
Kingdom andhas been drivenby4 mainresearch groups,
associated particularly with the names of Garety,
Kuipers, and Fowler in London and East Anglia, Tarrier
and Bentall in Manchester, Kingdon and Turkington
in Southampton and Newcastle, and Birchwood and
colleagues in Birmingham. These groups published a
sis, which have now been the subject of several meta-
analyses.79–82The last of these covered 14 randomized
controlled trials (RCTs) (N = 1484). Studies have varied
in their approach with some negative findings. Overall,
there is an effect size of around 0.37 for CBT, with
best effects on improvements in persistent positive symp-
toms. All trials include participants already on antipsy-
chotic medication. Jones et al81call CBT ‘‘a promising
but under-evaluated intervention.’’ There is some evi-
dence emerging for the value of early intervention serv-
ices and for intervention in prodromal states, but there
are few controlled trials of treatment at this stage.83–87
In the United Kingdom, the National Institute of Clin-
ical Excellence published guidelines for the treatment of
schizophrenia on the basis of its own review of the evi-
to those with persistent positive symptoms of psychosis
for at least 10 sessions over at least 6 months. This guide-
line will be reviewed 2006/2007.
The Importance of Engagement
In line with our treatment manual89and those of other
groups,90–93we have established that intervention to
help people with persistent positive symptoms requires
consideration ofengagement and the formationof a ther-
apeutic alliance, not just in early sessions but throughout
Cognitive, Emotional, and Social Processes in Psychosis
treatment (R. Rollinson, B. Smith, S. Steel, S. Jolley,
J. Onwumere, D. Freeman, P. A. Garety, E. Kuipers,
P. E. Bebbington, G. Dunn, M. Startup, D. Fowler, un-
published data, 2006). This entails therapists taking re-
sponsibility for keeping sessions nonaversive. It also
requires that therapists remain aware of the possibility
that the patient may have cognitive deficits such as
poor concentration, poor memory, or poor executive
and planning abilities and tailor interventions appropri-
ately. Sessions may need to be kept short and be con-
ducted flexibly; adhering to a rigid agenda may not be
appropriate. It is also likely that during sessions, an in-
dividual may become suspicious of the therapist or other-
wise distracted by cognitive distortions or intrusions such
as voices. Therapists need to be alert to such probabilities
to check them out and discuss them and, if possible, re-
assure the client, aiming in the process to reduce the am-
biguities that can cause such disturbances. The aim of
sessions initially, say the first five or six, is to conduct
a thorough assessment and from this to collaborate in de-
be shared by the therapist and the client. This then leads
on toappropriatecognitiveand behavioralinterventions.
Managing Affect in Hallucination and Delusions
We know from the research described above that depres-
sion, anxiety, and social isolation are particularly as-
sociated with the development and maintenance of
hallucinations and delusional distress.42In order to offer
effective treatment, it is often helpful to consider assess-
ing and treating the affect that usually precedes and
accompanies distressing voices44and trying to interrupt
cycles of low mood and anxiety. Clinically, it can be seen
that introducing behavioral activity scheduling for low
mood can not only improve affect but may also itself re-
duce isolation and improve social networks and social
support. Monitoring and enhancing coping strategies
for hallucinations can be helpful in reducing feelings of
powerlessness and pessimism and improving the effec-
tiveness of coping.29This in itself can sometimes reduce
the frequency of voices.94
Our model particularly focuses on the importance of
reappraisal, especially of negative beliefs.46We know
that delusional distress for instance is related to negative
illness appraisals,51and it can be helpful to decatastroph-
ize symptoms, to discuss and manage stigma and nega-
tive illness consequences, and to emphasize recovery
models.13Trower et al,29in an RCT for individuals
with command hallucinations, found it particularly help-
ful for individuals to deal directly with the consequences
of the commands and to discover that the voices were not
to changes in cognitions of power and control.
It can also be useful to reappraise external attributions
as internal states, so that individuals can recategorize
paranoid ideas as internal worries, critical voices as
mirroring self-blaming cognitions, or as memories of
the critical voices of others.43
Work on Negative Schemas and to Manage and
Given the research on abuse72and its effects on schemas
and views about the self, other people, and the world,41,95
together with the likely increase in intrusions that can re-
sult,75interventions may need to be attempted at the
schema level. Work on reevaluating underlying schema
and understanding how they continue to feed into the ex-
perience of negative voices or delusional ideas such as
paranoia may be particularly useful for those with histo-
ries of abuse that continue to be triggered by everyday
events and render people vulnerable to relapse.96
We know that isolated or critical social settings relate
to dysfunctional affect, poor self-esteem, and increased
positive symptoms.69,43Work on such aversive environ-
ments can help in reducing tensions, negotiating changes,
managing disagreements, and building up more support-
ive and positive environments. If carers are involved,
family interventions97–100may reduce relapses of positive
symptoms and improve functioning.88
Dealing With High Conviction; Helping to Compensate
for Reasoning Biases
We know that delusional conviction relates to JTC,52
which is in turn linked to belief inflexibility and an inabil-
ity to generate alternative explanations.54This suggests
that for those people who hold their beliefs with strong
conviction, it is important to work slowly on the ac-
knowledgment that other explanations are credible. It
may be necessary for the therapist to provide these be-
cause clients may not be able to generate them for them-
selves. Testing out new explanations to see if they are
credible seems to be an important part of this process
and should be attempted if possible.
Developing new strategies for clients to gather more
information before making a decision can help with
JTC biases and can become part of a more general style
clusion. We also know that disconfirmation is less com-
monly used as a way of testing competing theories about
what is happening: individuals usually employ confirma-
tory strategies.54Looking instead for instances, which do
not fit in with predictions (eg, not everyone I passed was
looking at me), can help to counter both confirmation
and attributional biases.
Therapists should try to work collaboratively with cli-
ents to ‘‘see what happens’’ and encourage the gradual
dropping of safety behavior and avoidance.49Clinical ex-
perience suggests that this has to be done slowly and in
E. Kuipers et al.
small steps in order to reduce dysphoria-induced worsen-
ing of symptoms of psychosis. It is a good argument for
not using ‘‘flooding’’ techniques with this population.
We are still developing CBT for the treatment of the dis-
tressingdelusions and hallucinationsassociated with psy-
chosis. There is some evidence that it can be helpful,
particularly for persistent positive symptoms, and good
evidence that it does not make things worse. It does
not, for instance, increase suicide rates.6Our research
group has been interested in specifying a cognitive model
of such symptoms in order to test out putative mecha-
nisms that elicit and maintain them. Results so far pro-
vide evidence for the influence of several of the
hypothesized cognitive, emotional, and social factors.
These are already improving our understanding of symp-
tom dimensions and leading to a clearer rationale for
intervention. Our current study, not yet completed,
will allow us to investigate the mechanisms of any ther-
apeutic change. This should in turn illuminate the pro-
cesses involved in symptom formation and maintenance.
Untangling worries of things that might be,
Controlling and broadcasting all about me,
The tills in the shops or a panic alarm,
Untangling worries that may cause me harm.
Untangling voices for they cannot hurt
And I’m in control and I’m on the alert,
A voice has no body, it’s all an illusion,
Untangling voices and all their confusion.
Extracts from an untitled poem by Wendy Baker, repro-
duced with the author’s permission.
This work was supported by a programe grant from the
Wellcome Trust No. 062452.
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