Cognitive Behavioral Therapy for Psychosis: a Critique

There are various things I dislike about CBTp.  Before explaining why let’s review an early iteration (Kingdon, Turkington and John. “Cognitive Behaviour Therapy of Schizophrenia: The amenability of delusions and hallucinations to reasoning.” British Journal of Psychiatry (1994), 164, 581-58):

“Positive symptoms are all theoretically amenable to structured reasoning and behavioural approaches. Symptoms are traced back (‘examining the antecedents’) to the approximate time of their onset. Inductive questioning may be used to identify faulty cognitions from this period. Attempts are made to understand delusional beliefs in collaboration with the patient by examining why significance was attached to specific events or circumstances. Alternative explanations are then debated using a normalising rationale where appropriate. “

“Working cognitively with the emotional investment of delusions can also be effective although with mood-syntonic delusions (for example, elated mood with grandiosity, or paranoia with anger) the alternative and more penetrating technique of inference chaining has been used. This involves tracing a delusion to its underlying irrational belief and its implications. Direct confrontation is avoided and tactical withdrawal used when necessary to retain rapport. With hallucinations, reality-testing is used to establish the uniqueness of the phenomena to the patient themselves. Alternative explanations then given consider evidence that hallucinatory phenomena can be related to stressful circumstances. Delusions of control and thought broadcasting can be compared to cultural beliefs in supernatural forces which allow rational argument to be used; for example, the scientific arguments and experimental evidence against the existence of telepathy can be utilised.”

So what’s the problem here (aside from the fact that any half-way intelligent person would be insulted by Kingdon et al’s manifest paternalism and condescension)? The problem is that both the “alternative explanations” that patient and therapist “collaboratively” construct  as well as their joint empirical “reality testing” assume that the “patient’s” conditions of possibility of reality (or “bedrock” or “background”) are the SAME as those that undergird “consensual reality.” Manifestly, at least in my experience, they are not.  So-called delusions are in fact taking place in another reality—made possible by fundamentally changed epistemological and ontological conditions.  Irrational thinking is not the problem—indeed there is no truly irrational thinking—only thinking that proceeds according to a different paradigm.  Huge problem with the theoretical foundations of CBTp? Yes.

Does CBTp sometimes work in spite of this? Yes, because there is always (or at least there can be) a dialogue between delusional reality and consensual reality. Thus, in some cases, some of the time, the logic of one can be used to cancel out (or at least lessen) the “logic” of the other. And yet this does not really change or restructure the “delusional” experience itself….

A second problem is that CBTp grossly oversimplifies the relationship between cognition, affect, perception and action.  Clearly these concepts—all of which are problematic in their own right—are profoundly interconnected (in complex and multi-directional ways).  Changing “maladaptive cognitions” and “negative schemas” without directly addressing affect and perception is only going to get one so far…

Why, then, does there seem to be so much empirical support for CBTp?  Honestly I think part of the reason is that a lot of people (“patients”) are simply not articulate enough to describe to therapists or researchers what is “actually” going on.  Perhaps this is because so much of “psychosis” is tacit–and because, in order to “articulate” madness, one must translate fundamentally ineffable experiences into (and through) the logic and syntax of language (and hence, by extension, “reason” such as it is understood within the Western philosophical tradition. [Poetry, perhaps, is the only way out of this "double bind."]).