Testing Hypotheses and Looking for Alternatives (Sessions 7 to 12)

In this chapter we highlight the CBT for psychosis techniques needed for the second part of the therapy. We offer concrete examples of how to present the CBT model and techniques in a group setting, using short movies and neutral examples, before tackling personal beliefs. Most techniques and activities start from the outside in, meaning that to avoid threatening participants, they first practice the concepts with fictional examples before attempting to apply them to themselves. The chapter takes each session of the second section of the workbook and explains in detail the purpose of each activity, how to conduct it, and gives clinical examples to illustrate participants’ reactions to these sessions.

Getting Started

This chapter covers all that needs to be put in place prior to starting a CBT for psychosis group and how to ensure attendance. We discuss what needs to be considered in terms of recruitment according to the setting, selection of participants (e.g. homogeneous group or not), the choice of the setting, schedule and frequency of sessions (e.g. once or twice a week), the advantages of using of a participant manual or workbook, and material that need to be planned ahead (e.g. flip-charts, snacks). The chapter also covers transportation issues, problems with attendance, vacation breaks or missed sessions, and proposes to consider measuring outcomes expected in terms of participant change at the end of the group.

Obstacles to Group CBT for Psychosis

Various obstacles can be encountered during group CBTp, either before the therapy, during the therapy, or even after the therapy. This chapter offers concrete examples of different obstacles that can be met as well as specific solutions for each obstacle. Some of these obstacles are setting-specific, such as lack of support from management or staff resistance to a new group, whereas some are more therapist-related (e.g., feeling incompetent, not getting along with the co-therapist). Regarding obstacles that are more client-related, we present a list of commonly encountered difficult or challenging participants in group CBT for psychosis and offer suggestions regarding how to best deal with them. This chapter essentially offers a plethora of solutions to common obstacles and challenges met when delivering group CBT for psychosis.

Measuring Change

The success of cognitive behavior therapy in general, as well as CBTp, stems in great part from demonstrating changes in symptoms over time, with measures showing improvements between pretherapy and both post-therapy and follow-up. This chapter proposes measures that can be used quickly and efficiently in a clinical setting to demonstrate the impact of the group CBTp. Measures specific to CBT for psychosis such as the CHOICE, as well as measures of concepts that have shown improvements following CBTp, such as symptoms, self-esteem, coping skills, social support, self-stigma, and social functioning, are described. Other measures of interest to assessing processes in therapy, such as alliance with therapists, group cohesion, participation within the group, and measures of treatment fidelity or therapist competence are also suggested.

The Role of the Therapist in Group CBT for Psychosis

The therapist has a very different role in group therapy than in individual therapy—these differences are presented in this chapter. This chapter presents how to work in co-therapy, how to use the participants’ input to support the therapist, and what is expected of the therapist (e.g., show and ensure understanding, manage time and interactions, encourage group cohesion). The chapter also offers a detailed list of ‘to-do’ (e.g. protecting self-esteem, offer structure) and ‘do not’ (e.g., imposing his/her view, acting as an expert, monopolizing the session) that therapists need to keep in mind when offering gropu CBT for psychosis.

Basic Cognitive Behavioral Model Used in Group CBT for Psychosis

This chapter reviews the essential CBT model, such as the ABC’s of CBT model, as well as the specifics linked to psychosis in terms of cognitive biases (attributional, reasoning, etc) and different core beliefs, either specific to psychosis or shared by other disorders, such as depression or personality disorders. Cognitive and behavioral theories, linking biases as well as cognitive and metacognitive deficits, to positive symptoms such as paranoia, grandiosity, and negative symptoms are also presented. Other models used in group CBT for psychosis, such as the recovery model, which focuses on hope in the future, taking personal responsibility for oneself, and getting on with life, or the vulnerability-stress-competence model—empowering the person in developing protective factors to avoid relapse, are explained. The chapter also presents the single-session model, enabling participants to gain from each group session, and Bandura’s social learning theory, as useful for group CBT for psychosis.

CBT Groups for Psychosis With Other Targets

Groups using CBT principles or techniques but targeting either a specific symptom or a domain outside of typical CBT for psychosis have been developed and tested. Some of these groups have been presented briefly in Chapter 3 and have demonstrated their empirical efficacy. In this chapter we present them in more detail. Specifically, we present a group approach focusing on voices, another aiming at improving participants’ self-esteem, a group targeting stress management in people with severe mental illness, and CBT for work integration of people with severe mental illness participating in supported employment programs. The chapter also describes a CBT group for parents or family members of individuals with psychosis, which seems to be effective.

Drugs, Alcohol, and How I Feel (Sessions 13 to 18)

This chapter describes the third section of the workbook, which focuses on the emotional and behavioral manifestations of distress, as well as on self-esteem, and further develops the concept of coping strategies. Distress, specifically substance misuse and suicidal thoughts, is not specific to individuals with psychosis but is prevalent in this population. CBTp therapists will focus on distress but will also focus on strengths and goals, which means the therapy will target not only psychotic symptoms but also other distressing emotions and behaviors. Similarly, the therapy should focus on the person’s strengths, capacities, and goals that go beyond distress reduction. The chapter takes each session of the third section of the workbook and explains in detail the purpose of each activity, how to conduct it, and gives clinical examples to illustrate participants’ reactions to these sessions.

Essential Elements of Group Therapy

This chapter describes the unique elements of group therapy in general as well as in group CBT for psychosis more specifically. Special attention is given to Yalom’s essential elements of group therapy and how most of these are applied in group CBT for psychosis. Elements such as normalization of experience, socialization, social support, interpersonal learning, group cohesion, task focus, a safe and respectful environment, and a goal-oriented approach are described and illustrated. Elements specific to our group CBT for psychosis approach, such as avoiding the psychiatric vocabulary and ensuring that the group is an enjoyable experience are presented. Also the importance of using a single-session time frame is put forward.

History of Group Therapies for People With Psychosis

Group interventions have been offered in institutionalized settings for many decades. This chapter reviews the changes in goals and purposes for group therapies over the years. The chapter presents the goals, results and at times pitfalls of various group approaches. For instance, the book covers the first psychoanalytical groups offered to people with severe mental illness, followed by artistic and psychodrama groups. The chapter presents how the 1950’s saw the mergence of milieu therapy, closely followed by encounter groups. Specifically addressing people with severe mental illness, Yalom, and later Kanas, developed their models of inpatient group therapy, that are presented here. Finally, the chapter reviews some group approaches still used today, namely skills training, cognitive skills groups, peer support groups and dual-diagnosis groups.