This programme is a treatment manual for mental health professionals. It assumes clinical training in cognitive behavioural therapy for psychosis, work in liaison with a psychiatrist and a team, and a supervision framework. It replaces neither your clinical judgement nor your professional responsibility. Diagnostic criteria are reworded here in our own words, never reproduced. Two warnings specific to this indication. An acute relapse calls for immediate psychiatric assessment; the programme is paused, and resumes afterwards. And medication belongs to the psychiatrist: no change is discussed or arranged without them, section 10.
1. The programme at a glance
Indication. Adults with established schizophrenia — after several episodes or with persistent symptoms — followed as outpatients by a psychiatrist, outside an acute phase.
Reference model. Recovery-oriented cognitive behavioural therapy for psychosis: an alliance built on the person's goals, normalisation of experiences, a shared formulation, work on beliefs about voices and on persecutory ideas, an approach to negative symptoms through activity and defeatist beliefs, work on self-stigma, a relapse prevention plan, and family intervention, coordinated with the team for employment, housing, physical health and cognitive remediation.
Format. Sixteen key sessions over nine to twelve months, often longer, weekly then spaced out. 45- to 60-minute sessions, sometimes shorter and more frequent depending on concentration. At least one session with the family, and a family intervention over several sessions when possible. Booster sessions.
Targeted mechanism. Reducing the distress and intrusiveness of psychotic experiences by changing the beliefs and behaviours that maintain them, rekindling activity and relationships, reducing self-stigma, preventing relapse through recognition of early signs and continuity of care, and supporting a chosen life.
| Phase |
Session |
Topic |
Session output |
| I. Engaging |
1 |
Meeting the person, not the file |
The person's concerns and interests gathered |
|
2 |
Recovery goals |
Two or three life goals written down |
|
3 |
Assessment |
Risks, health, substance use and functioning assessed |
| II. Understanding |
4 |
The history, and what has helped |
Timeline drawn with what helped and harmed |
|
5 |
Human experiences |
Model explained, experiences normalised |
|
6 |
The cycle of a distressing experience |
Shared formulation of a real episode |
| III. Symptoms |
7 |
Voices |
Beliefs about voices explored, one behaviour changed |
|
8 |
Frightening ideas |
Other explanations, one experiment done |
|
9 |
The missing drive |
Defeatist beliefs identified, activities planned |
|
10 |
Mid-point review |
Measures repeated, plan revised |
| IV. Living |
11 |
The label and self-esteem |
Self-stigma addressed |
|
12 |
Loneliness and relationships |
A relationship renewed or created |
|
13 |
Work, activity, body |
A step towards employment or activity, a health goal |
| V. Consolidating |
14 |
My prevention plan |
Early signs and plan written and shared |
|
15 |
The family |
Joint session, written agreement |
|
16 |
Review and next steps |
Measures repeated, booster sessions scheduled |
What the person takes away. Seven printable worksheets, listed in section 42: what I want for my life, my cycle, my voices, getting going again, what the diagnosis does not say about me, the corner for family and friends, my prevention plan.
What sets this programme apart from the other manuals on this site. Three things. A recovery goal that does not depend on symptoms disappearing. Experiences that are worked with instead of fought against. And care for the body, housing, employment and family, because these often decide people's lives.
2. Before you begin
Who this programme is for
For psychologists, psychiatrists, nurses and psychotherapists trained in cognitive behavioural therapy for psychosis, working in a team or in close liaison with a psychiatrist. It is not intended for patients or their families.
When to start
Not during an acute relapse. Brief, regular contact can be maintained; the work resumes once the episode is contained.
Not only when everything is going well. People with persistent symptoms despite treatment are those for whom cognitive behavioural therapy for psychosis has been most studied.
The four preliminary decisions
1. Is risk organised? Suicide, violence, vulnerability, self-neglect. Section 9.
2. What is the psychiatric follow-up, and who does what in the team? Section 10.
3. What are the person's priorities? They may be housing, money or loneliness before voices. Section 17.
4. What role for the family? Section 36.
What this programme does not treat
An acute relapse.
A first episode of psychosis, which has its own manual, focused on young people and early intervention.
Severe disorganisation or catatonia, which call for medical care first.
Severe, unstabilised addiction, which calls for integrated work.
What this programme is not
It is not an adherence programme, nor re-education, nor a psychotherapy that would replace medication or the team. Nor is it work that waits for symptoms to disappear before taking an interest in life.
How to use it
First read sections 3 to 15, then sections 32, 33 and 35 before the first session. The sessions described are key sessions; phase III often takes several for each. Section 43 says what must not be let go.
3. The clinical picture
The dimensions
Positive symptoms: delusions, particularly persecutory and referential; hallucinations, mostly auditory — voices that comment, converse, criticise, command; experiences of influence, control or thought theft.
Disorganisation: speech that is hard to follow, derailed thinking, disorganised behaviour, inappropriate affect.
Negative symptoms: reduced drive and initiative, social withdrawal, reduced anticipatory pleasure, diminished emotional expression and speech.
Cognitive difficulties: attention, working memory, processing speed, executive functions, social cognition. They weigh heavily on functioning.
Affective symptoms: depression, anxiety, hopelessness, common at every phase.
What people describe
Voices with a personality, sometimes years of shared history, often humiliating, sometimes reassuring. Fear of being watched, targeted, poisoned. Fatigue, the feeling that "nothing is worth it", the sense of being switched off. Loneliness. How others look at them, and how they look at themselves. Hospitals, treatments, the loss of a job, a relationship, an imagined future. And often great clarity about all of this.
What you see in the consulting room
Everything and its opposite: a person who talks readily about their voices and another who keeps quiet out of mistrust; a lively person and another who is slowed down and answers in monosyllables; a clear conversation and one that loses its thread. Do not confuse little expression with little feeling, nor slowness with lack of interest.
Epidemiology
Schizophrenia affects around 0.3 to 0.7% of the population over a lifetime. It most often begins between late adolescence and the early thirties. It is more common in urban areas, in some migrant and minority populations, and is associated with genetic, developmental and environmental factors — trauma, high-potency cannabis, social adversity.
Course
Very heterogeneous. Some people have few episodes and good functioning; others have persistent symptoms and significant disability. Relapses are common, and stopping treatment markedly increases their risk. Social functioning depends as much on negative symptoms, cognitive difficulties, access to employment and housing, and stigma as on positive symptoms.
Life expectancy is reduced by more than ten years on average, mainly through cardiovascular and respiratory disease, and also through suicide. Section 37.
4. Recovery
Why this section exists
Because the word covers two different things, and confusing them leads either to discouragement or to neglect.
Clinical recovery
Remission of symptoms and return of functioning, measured against criteria. By these strict criteria and over time, reviews show that a minority of people reach it, with large variation according to studies and definitions; many more experience periods of remission and partial improvement.
Personal recovery
A process through which the person builds a life that is meaningful to them, with or without symptoms: hope, connection, an identity not reduced to the illness, a role, a sense of agency. It was described from the testimony of people themselves, and it now guides many care systems.
What this changes for you
You measure symptoms, and you measure life. You do not make the disappearance of voices a condition for returning to work, a relationship or a project. You hold hope without promising, and you never reduce the person to their prognosis.
5. The model
The model that guides this programme is presented to the person in plain language, starting from their experience.
Stress and vulnerability
A vulnerability specific to the person — genetic, developmental, linked to their history — meets stressors — lack of sleep, cannabis, conflict, isolation, difficult events, discrimination. When the load exceeds a threshold, psychotic experiences increase and an episode may occur. What protects — treatment, sleep, relationships, activity, support, stress management — raises the threshold.
The continuum of experiences
Hearing voices and having persecutory or referential ideas are experiences that exist, more or less frequently and intensely, in the general population. What causes suffering is their frequency, their interpretation and their consequences.
What maintains positive symptoms
Anomalous experiences — a voice, a perception, a sense of significance — receive a threatening and external interpretation, under the influence of emotion — anxiety, depression, anger — of beliefs about self and others — "I am vulnerable", "others are hostile" — of reasoning biases — jumping to conclusions, not considering alternatives — and of the social context. Safety behaviours — avoiding, obeying, hiding, watching — prevent checking and maintain fear.
What the person believes about their voices
Distress linked to voices depends heavily on what the person believes about them: their power, their malevolent or benevolent intention, what will happen if they do not obey, what they know about the person. A voice perceived as all-powerful and malevolent produces fear, submission or struggle; the same voice, perceived differently, is less disturbing.
What maintains negative symptoms
Beyond what is linked to the disorder itself, defeatist beliefs — "what's the point", "I'll fail", "I won't enjoy it", "others will reject me" — reduce initiative, persistence and anticipated pleasure. Withdrawal, isolation, depression, sedation from medication, lack of opportunity and stigma add to them. These factors can be worked on.
What the model explains to the person
That their experiences are real to them and human. That some things make them stronger and more distressing, and others calm them. That what they think about their voices and fears can change what these put them through. That lack of drive is not laziness. And that a life that suits them can be built now.