Schizophrenia: cognitive therapy and recovery — a therapist's manual

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 (section 35).

Format. Sixteen key sessions over nine to twelve months, often longer, weekly then spaced out; a key session, especially in phase III (sessions 7 to 10, see the table below), often takes up several meetings, so the actual number of meetings is well above sixteen. 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. Three booster sessions after the end of the programme, at one, three and six months, with their dates set at session 16.

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 circle, my voices, getting going again, what the diagnosis doesn't 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

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. Has risk been assessed, and is its management 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, First-episode psychosis: a therapist's 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, that is, treatment of the addiction and of the psychosis carried out at the same time, by the same team or by coordinated teams, rather than one after the other.

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, ideas of reference being the impression that trivial events, such as a glance, a laugh or a television programme, concern the person or are sending them a message; hallucinations, mostly auditory — voices that comment, converse, criticise, command; experiences of influence, control or thought theft (section 34).

Disorganisation: speech that is hard to follow, derailed thinking, disorganised behaviour, inappropriate affect, that is, emotional expression out of step with the situation, such as laughing while recounting a sad event.

Negative symptoms: reduced drive and initiative, social withdrawal, reduced anticipatory pleasure, that is, the pleasure one expects from an activity to come, diminished emotional expression and speech.

Cognitive difficulties: attention, working memory, processing speed, executive functions, social cognition, that is, the ability to recognise emotions and to understand other people's intentions. 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. Its incidence is higher in urban areas and in some migrant and minority populations, and it 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 (Hjorthøj et al., 2017), 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 (Jääskeläinen et al., 2013), 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 (Anthony, 1993; Slade, 2009).

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 brings together the stress-vulnerability model (Zubin and Spring, 1977), the cognitive model of positive symptoms (Garety et al., 2001), the cognitive model of voices (Chadwick et al., 1996) and that of negative symptoms (Beck et al., 2009). It 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, the impression that trivial details have a particular 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.

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