Understanding Psychosis: Cognitive Behavioural Therapy for Psychosis (CBTp) and Psychotic Experiences

Daniel, a twenty-year-old university student (case description adapted from Hardy & Turkington, 2023), dropped out of university and withdrew into his home after developing the distressing belief that people around him could hear his thoughts. Intrusive thoughts with sexual and racist content filled him with profound shame, and he began interpreting other people’s incidental behaviours, such as a fellow student shifting in her chair during class, as evidence that they were aware of his thoughts and disgusted by them. In an effort to reduce his anxiety, Daniel gradually limited his time outside the house, began sleeping during the day and staying awake at night, and consumed large amounts of caffeine so that he could remain awake during the hours when fewer people were around.

When working with someone who holds such a powerful belief, therapists may sometimes feel that their treatment options are limited. Should the belief be challenged? Should it be ignored? Or should treatment focus primarily on reducing symptoms through medication? These questions lie at the heart of Cognitive Behavioural Therapy for Psychosis (CBTp), an approach that seeks to understand the psychological function of psychotic experiences and to help people develop new ways of relating to them.

Psychosis is commonly described as a mental state characterised by substantial changes in reality testing and may involve changes in thinking, perception, judgement, and the organisation of behaviour and speech. Within mainstream clinical discourse in Israel, psychosis is often explained primarily in biological terms, sometimes without sufficient attention to the psychological meaning of the person’s experience (Fišar, 2022). As a result, clinicians may avoid engaging with the content of psychotic experiences, while treatment becomes focused mainly on the pharmacological management of symptoms. Yet both clinical experience and research suggest that when the subjective meaning of psychotic experiences is not given space within therapy, recovery may be impeded (Hagen, Turkington, & Berge, 2010).

Cognitive Behavioural Therapy for Psychosis (CBTp) is one of the most extensively researched and strongly recommended psychological interventions for psychosis (Hazell et al., 2016; Sitko et al., 2020; Laws et al., 2018).

International clinical guidelines recommend CBTp as a first-line psychological intervention alongside pharmacological treatment (NICE, 2014; Wood et al., 2020; Turner et al., 2020). Rather than viewing psychosis as simply a breakdown of normal mental functioning or a “brain malfunction,” CBTp understands it as part of a continuum of human experience. The approach is less concerned with judging a belief as objectively true or false than with understanding how it developed and what function it serves in the person’s life, often as a response to trauma, social isolation, or chronic stress (Hardy & Turkington, 2023; Hardy et al., 2022). To understand how this perspective emerged, it is helpful to briefly examine the shift between the major models of psychosis.

Terminology

This article is intended for clinicians and therefore uses professional terminology that may at times feel value-laden. Terms such as delusions, hallucinations, and paranoia are neither self-evident nor universally accepted across theoretical perspectives. Contemporary CBTp literature increasingly favours alternative terms that place greater emphasis on the person’s lived experience, such as persecutory beliefs, unusual experiences, or unusual beliefs (Hardy & Turkington, 2023). The terminology used throughout this article has been chosen primarily for clinical clarity and readability, while recognising the complexity of these concepts and the importance of reducing stigma.

From the Medical Model to the Cognitive Model

For many years, two major perspectives dominated the understanding of psychosis. Classical psychoanalytic theory viewed psychosis as the expression of profound intrapsychic pathology. For example, Fromm-Reichmann (1948) proposed that complex processes within the early mother-child relationship could contribute to the development of schizophrenia, a theory that was later criticised on both empirical and ethical grounds because of the unjustified burden it placed on families. The biological-medical model, by contrast, locates the origins of psychosis in genetics, neurobiology, and brain-based risk factors (Fišar, 2022). While this perspective reduces blame and shame directed toward both individuals and their families, it can also leave people with the impression that meaningful psychological change is unlikely. Against this background, the cognitive model of psychosis emerged as an attempt to restore a sense of understanding and therapeutic agency. According

to this model, people experiencing psychosis are not to blame for becoming caught in confusing and distressing patterns of thinking and behaviour. At the same time, collaborative therapeutic work can help both therapist and client understand how these patterns developed and how they may gradually be changed. Central elements of this approach include a therapeutic relationship grounded in empathy, normalisation, and collaborative case formulation that links symptoms to the individual’s personal history and social environment (Hagen, Turkington, & Berge, 2010; Garety et al., 2001).

Core Principles: Normalisation, Befriending, and the Therapeutic Relationship

The foundation of CBTp is the therapeutic relationship, built upon care, hope, and befriending. These principles are not merely guiding values; they are therapeutic interventions in their own right and form the backbone of the entire treatment process.

Normalisation

Experiences such as hearing voices or having unusual thoughts are far more common than most people realise. An important part of therapy is helping clients recognise that their experiences are not entirely separate from the broader range of human experience. Intrusive and unusual thoughts occur in many people; what differs is the level of distress they evoke and the meaning attached to them. The aim of normalisation is to reduce shame and isolation, making it easier to talk openly about these experiences.

Befriending and Collaboration

The therapist seeks to establish a collaborative, non-hierarchical therapeutic alliance based on shared curiosity. This does not mean agreeing with the content of a person’s beliefs. Rather, it means validating the client’s emotional experience and demonstrating a genuine willingness to understand how the experience makes sense from their perspective.

The Therapist as a Safe Haven

The therapist serves both as a bridge back to the social world and as a source of emotional regulation presence. Speaking slowly, maintaining a calm tone of voice, and adopting open, non-threatening body language all communicate safety to the client’s nervous system. Giving clients a sense of control over the physical environment

and over the therapeutic dialogue can further enhance their sense of safety. For example: “Would you like us to leave the door slightly open? Or would it feel more comfortable if we sat a little farther apart?” Small adjustments such as these often make it easier for dialogue and trust to develop within the therapeutic relationship.

Validating the Experience—Not the Content

Rather than arguing with the logic of a paranoid belief, the therapist attempts to validate the experience that lies beneath it—the emotions, thoughts, beliefs, and bodily sensations associated with it. For example: “I can see that you’re feeling threatened right now. Would it be helpful if we thought together about how we could make this room feel safer for you at the moment?” To illustrate how these principles are applied in practice, let us return to Daniel, whose story opened this article.

Case Example 1 – Daniel

Daniel struggled with intrusive thoughts that filled him with shame and interpreted other people’s incidental behaviours as evidence that they were aware of his thoughts. The first stage of therapy focused on normalisation. His therapist explained that intrusive thoughts are a very common human experience and do not reflect a person’s character or indicate that their thoughts are somehow being “broadcast” to others. Together, they explored alternative explanations for the behaviour of people around him—for example, that the student who shifted in her chair during class may simply have been uncomfortable. At the same time, Daniel began to recognise how the coping strategies he had developed around his anxiety—including excessive caffeine consumption and reversing his sleep schedule—were actually increasing his tension and intrusive thoughts. As therapy progressed, he gradually began completing behavioural tasks that involved leaving the house during daylight hours while reducing his caffeine intake.

By combining cognitive reappraisal, gradual behavioural exposure to anxiety- provoking situations, and the development of more adaptive coping strategies, Daniel gradually returned to university and became socially engaged once again.

Case Formulation of Psychotic Experiences: Understanding Voices and Delusions in CBTp

Case formulation lies at the heart of CBTp. It is the collaborative process through which therapist and client work together to understand how psychotic experiences developed and what continues to maintain them. Rather than viewing voice-hearing or unusual beliefs as isolated symptoms, formulation explores the relationships among life experiences, emotions, interpretations, and patterns of behaviour. The goal of formulation is to understand the role these experiences play in a person’s life and to make sense of voices and beliefs that may initially appear irrational (Viglin, 2021). A good formulation should remain focused. Rather than attempting to explain an individual’s entire life history, it should concentrate on the factors most relevant to the person’s current crisis and the difficulties that have brought them to therapy (Spencer, 2025). Modern psychiatry has been strongly influenced by the work of Karl Jaspers. Jaspers described delusions as beliefs characterised by strong conviction, resistance to counter-evidence, and unusual or bizarre content. However, he also argued that these characteristics alone do not define delusions. What distinguishes them, he suggested, is that they cannot readily be understood within the context of the person’s life (Jaspers, 1913, as cited in Hardy & Turkington, 2023). Contemporary approaches—and CBTp in particular—offer a different perspective. Voices and delusions are understood as dynamic experiences shaped by personality, developmental history, and life events. Their emergence and evolution can therefore be explored and understood over time. Research suggests that conviction is not fixed but exists on a continuum, varying according to context, emotional state, and therapeutic intervention (Feyaerts et al., 2021; So et al., 2015). Approximately 7–10% of the general population report hearing voices at some point in their lives without ever receiving a psychiatric diagnosis or requiring mental health treatment (Maijer et al., 2018; Kråkvik et al., 2015; Johns et al.,

2014; Sommer & Daalman, 2010). Most people seek treatment only when the voices become dominant, hostile, or increasingly difficult to cope with (Johns et al., 2014).

Key Dimensions of Case Formulation

Meaning and Intentionality

How does the person understand the experience? Is the voice experienced as an external agent with intentions of its own, or as part of the self? Is the belief experienced as a threat, a source of protection, or an explanation? The meaning attributed to the experience is one of the strongest determinants of distress.

Personal Context and the Grain of Truth

Case formulation seeks to identify the relationship between the content of psychotic experiences and the person’s life events, relationships, and emotional patterns. Sometimes this relationship is direct; at other times it is symbolic or metaphorical. Even when the literal content is not consistent with reality, it may represent an attempt to organise overwhelming inner experience into a coherent narrative.

Response Patterns and Safety Behaviours

The ways in which people respond to voices or unusual beliefs—through avoidance, compliance, or attempts at suppression—may reduce distress in the short term while inadvertently maintaining it over time by preventing new learning. Formulation also considers cognitive biases, such as jumping to conclusions, particularly under conditions of stress. Although these biases are not unique to psychosis, they may become amplified and contribute to the rapid development of rigid explanations.

Voice-Monitoring Diaries

One useful assessment and intervention tool is a voice-monitoring diary, in which clients record the context (What happened beforehand?), the content of the voices (What was said?), their level of distress (rated from 1 to 10), and how they responded. This process often helps people recognise that voices are not random events but are closely influenced by factors such as fatigue, cognitive overload, and specific social situations. Identifying these patterns is an important step toward restoring a sense of agency and control (Dollfus et al., 2024).

Case Example 2 – Eleanor Longden Eleanor Longden (2013) first began hearing a neutral voice while she was at university. The voice functioned almost like an objective narrator, commenting on her actions—for example, “She is leaving the room.” Initially, she did not experience this as problematic. However, the fearful reactions of those around her, followed by the responses of the psychiatric system, framed the experience as evidence of a serious mental illness. As these threatening interpretations were reinforced through coercive treatment, the voices gradually became hostile. They instructed her to harm herself, demanded that she carry out bizarre tasks, and threatened that something terrible would happen if she refused. At the height of her crisis, one psychiatrist told her: “It would have been better if you had cancer, because cancer has treatment. Schizophrenia doesn’t.” After several unsuccessful treatment experiences, Eleanor finally met a psychiatrist who believed in her and supported her throughout her recovery. Alongside CBTp, she benefited from a strong support network that included her mother, who never gave up on her, and friends who remained by her side. A major turning point came through her involvement with the Hearing Voices Network, where she discovered that hearing voices could be understood as a meaningful human experience rather than simply a symptom of illness. Gradually, she came to understand that her voices were not the result of a defective brain, but were closely connected to stress, childhood trauma, and painful experiences that had never found expression. The voices were carrying emotions that she had been unable to speak. Today, Eleanor Longden is a clinical psychologist and one of the leading researchers and advocates in the field of psychosis

Feeling Safe: A Targeted Intervention for Persecutory Beliefs

The Feeling Safe Programme, developed by Daniel Freeman (Freeman, 2021), is a targeted intervention for persecutory beliefs based on changing the person’s experience of threat.

The central premise of the model is that paranoia is maintained not only by the content of threatening beliefs, but by an ongoing experience of existential threat. Rather than attempting to disprove the belief directly, treatment focuses on helping people build experiences of safety. As individuals begin to feel safer, the conviction with which they hold persecutory beliefs often diminishes. The intervention targets several key maintaining mechanisms:

Reducing Safety Behaviours

Safety behaviours such as avoidance, hypervigilance, or repeated checking (for example, constantly scanning the environment, avoiding certain places, or repeatedly checking information) reduce anxiety in the short term. However, they also reinforce the belief that the world is dangerous because they prevent people from encountering corrective experiences. In therapy, these behaviours are identified collaboratively, and a hierarchy is developed for gradually reducing them. The emphasis is not on cognitively disproving the threat, but on creating direct experiences in which the individual functions without relying on safety behaviours and discovers that the feared outcome does not occur. Over time, these experiences accumulate into “memories of safety” that gradually reshape the person’s perception of the world.

Managing Worry (“Worry Time”)

Worry functions as one of the primary fuels of paranoia. It keeps attention focused on threat, increases vigilance, and encourages the interpretation of neutral events as dangerous. One of the programme’s core interventions is the practice of worry time. Clients schedule a specific period each day (for example, ten minutes, several times a day) during which they intentionally focus on their worries, write them down, and explore them in detail. Whenever worries arise outside these scheduled periods, they practise postponing them until the designated time. The aim is to change the person’s relationship with worry—from an uncontrolled, continuous process to one that is deliberate and time-limited. This often reduces cognitive overload and allows attention to shift back toward the external world and personally meaningful activities.

Improving Sleep

Sleep deprivation increases sensitivity to threat, impairs emotional regulation, and biases information processing toward danger. Consequently, treatment includes interventions aimed at improving sleep, such as principles drawn from Cognitive Behavioural Therapy for Insomnia (CBT-I), including maintaining regular sleep schedules, reducing physiological arousal before bedtime, and limiting time spent awake in bed. In many cases, improvements in sleep alone lead to noticeable reductions in paranoid thinking, even before cognitive or behavioural interventions are introduced.

Building Self-Confidence and Self-Efficacy

Feeling vulnerable—for example, believing “I’m weak” or “I’m an easy target”—increases the tendency to interpret the environment as threatening. Therapy therefore involves identifying negative beliefs about the self while gradually creating opportunities for success, meaningful activity, and improved daily functioning. As individuals experience themselves as increasingly capable of coping with life’s challenges, the need for constant vigilance and defensive behaviour begins to diminish.

Case Example 3 – Mary

Mary (case adapted from McTiernan, 2025) believed that Facebook was monitoring her and sending threatening messages through personalised advertisements. This belief created a self-perpetuating cycle. She repeatedly checked her account in an attempt to discover “what they know about me,” while simultaneously becoming increasingly socially withdrawn out of fear that other people might harm her. In therapy, Mary came to understand that her checking behaviours and avoidance, although intended to reduce anxiety, were actually maintaining her sense of persecution. They kept her attention focused on potential threats while preventing opportunities for corrective experiences. It also became clear that persistent worry (“What do they know about me?” “Who is watching me?”) together with disrupted sleep were increasing her feelings of vulnerability and fear. Following the Feeling Safe Programme, treatment focused on reducing checking behaviours by setting specific times for accessing social media, practising worry time to reduce persistent engagement with threatening thoughts, gradually re-engaging in social situations, spending more time

pursuing personally meaningful interests, and improving sleep and daily routines. Through these experiences, Mary gradually accumulated evidence that contradicted her beliefs. She experienced safe social interactions, discovered that nothing harmful happened even when she did not check for information, and learned that she could tolerate anxiety without relying on avoidance. As her sense of safety grew, the intensity of her persecutory beliefs gradually diminished.

Expanding the Therapeutic Toolbox: Complementary Approaches for Recovery and Functioning

Recovery-Oriented Cognitive Therapy (CT-R): Promoting Recovery and Empowerment in the Midst of Psychosis

Recovery-Oriented Cognitive Therapy (CT-R) is based on the assumption that even in severe psychotic states, the healthy core of the person remains intact. Beneath the pain and disconnection, aspirations for the future and a longing for connection continue to exist, and these represent the primary pathway to recovery. The model describes movement between two modes. The Disconnected Mode is characterised by withdrawal, hopelessness, and disengagement. The Adaptive Mode consists of those moments—however brief—in which the person reaches toward connection, creativity, purpose, or enjoyment. The therapist’s task is to actively identify and strengthen these moments. As individuals spend increasing amounts of time in the Adaptive Mode, psychotic symptoms tend to become less dominant and less threatening (Beck et al., 2020). Therapy begins by establishing a safe connection. Bridges into the Adaptive Mode are created through shared activities that naturally engage the person, ranging from listening to music together to watching a football match or playing a board game. From this foundation, therapy gradually shifts toward identifying aspirations.

Aspirations reflect deeply held values—for example, becoming a caring parent or creating meaningful artwork. Therapy becomes a collaborative space in which therapist and client work together toward these aspirations while gradually building experiences of competence, agency, and connection. CT-R approaches several common clinical challenges in ways that differ from traditional psychiatric perspectives.

Negative Symptoms (Withdrawal and Low Energy)

Rather than viewing negative symptoms primarily as deficits or incapacity, CT- R understands them as protective strategies. Treatment therefore focuses on creating an environment that feels both safe and engaging—one that encourages the individual to emerge from defensive withdrawal and gradually reconnect with meaningful activities.

Voices and Hallucinations

Rather than attempting to eliminate voices directly, therapy helps people focus their attention on what is meaningful in the present moment. As engagement with personally valued activities increases, the voices often become less dominant and intrusive.

Aggression and Lack of Engagement

Aggressive behaviour or apparent resistance to treatment is understood as an expression of intense threat and insecurity. Instead of responding confrontationally, the therapist focuses on strengthening the person’s sense of safety, control, and choice. As individuals spend more time in the Adaptive Mode and move toward their aspirations, their sense of identity gradually shifts, and psychotic symptoms become less central to their lives (Beck et al., 2020).

Acceptance and Commitment Therapy for Psychosis (ACTp)

Acceptance and Commitment Therapy for Psychosis (ACTp) complements the approaches described above (Morris et al., 2024; O’Donoghue et al., 2018). One of its central processes is committed action—helping people continue moving toward what matters to them, even when voices or other psychotic experiences remain present. Instead of engaging in an exhausting struggle to silence experiences that cannot be fully controlled, ACT encourages acceptance: making room for voices,

anxiety, and difficult internal experiences, recognising that attempts to suppress them often increase their intensity. Through cognitive defusion, individuals learn to relate differently to distressing thoughts. Rather than experiencing a thought as an unquestionable fact, they begin to notice it as an event occurring in the mind—for example: “I’m noticing the thought that…” Mindfulness practices that cultivate contact with the present moment, such as Dropping Anchor (Harris, 2021), help individuals reconnect with their immediate physical surroundings without becoming overwhelmed by the storm of internal experience. At the same time, ACT fosters self-as-context—a flexible sense of self that remains stable even while thoughts, emotions, and voices continue to change.

Case Example 4 – Patricia Deegan

The story of Dr. Patricia Deegan (Deegan, 1988, 1996) provides a powerful illustration of both CT-R and ACT principles. As a teenager, after being diagnosed with schizophrenia, she entered what she later described as her “Coca-Cola and Cigarettes Syndrome.” She spent her days watching television, drinking soft drinks, smoking cigarettes, and waiting for time to pass, caught in a state of profound hopelessness and loss of meaning. The turning point began with one small act of committed action. Every day, her grandmother invited her to come grocery shopping. Patricia repeatedly refused. Yet her grandmother continued to invite her without pressure or judgment. Eventually Patricia agreed to join her. At first she simply walked behind the shopping cart. Later she began pushing it herself. Gradually she returned to engaging in meaningful activities. This illustrates the movement from withdrawal toward action guided by connection and values. Deegan has described how she eventually decided that she wanted to become “Dr. Deegan” so that she could help others facing challenges similar to those she had experienced herself. In doing so, she transformed her suffering into a lifelong sense of purpose. She also recounts that during the darkest period of her illness she heard a voice telling her that she was “a kite blowing helplessly in the wind.” As her

recovery progressed and she gained increasing responsibility for her own life, the voice changed. It told her: “You are still a kite in the wind—but now you are the one holding the string.” This metaphor beautifully captures the shift from experiencing oneself as a powerless victim of symptoms to recognising that it is possible to steer one’s life, even while the storm continues.

Conclusion

This article has presented the diverse skills and approaches that fall under the umbrella of Cognitive Behavioural Therapy for Psychosis (CBTp). It has reviewed the core principles of case formulation and intervention, alongside complementary approaches that broaden the clinician’s therapeutic repertoire, including Recovery-Oriented Cognitive Therapy (CT-R), Acceptance and Commitment Therapy for Psychosis (ACTp), and the Feeling Safe Programme for working with persecutory beliefs. Like any therapeutic approach, CBTp has its limitations. The research literature presents a nuanced picture. Meta-analyses suggest that CBTp can reduce distress, increase cognitive flexibility, and improve aspects of functioning. However, its effects are not uniform, are often modest, and in some studies diminish over time (Hazell et al., 2016; Laws et al., 2018; Sitko et al., 2020). From a clinical perspective, CBTp is not equally appropriate for every person or at every stage of recovery. When someone is in an acute psychotic state—overwhelmed, highly disorganised, or lacking basic stability—the immediate therapeutic priority is not cognitive work but the establishment of safety, emotional regulation, reduction of arousal, and the development of a trusting therapeutic relationship. Similarly, when insight is extremely limited, when it is difficult to establish a therapeutic alliance, or when the individual is living under conditions of ongoing chaos and instability, cognitive interventions alone are likely to have limited effectiveness (Thomas, 2015). A growing body of research has demonstrated meaningful links between adverse life experiences and the specific content of psychotic symptoms (Bentall et al., 2014). Studies have reported elevated rates of psychotic symptoms among Holocaust survivors (Keller et al., 2026; Terno et al., 1998) and among members of the second generation (Levav, Kohn, & Schwartz,

1998). Other research has documented increases in psychotic experiences during periods of war in Israel (Mussa, Blizovski, & Koren, 2018), including following the events of October 7, 2023 (Fekih-Romdhane et al., 2025). In light of these findings, and based on the author’s clinical experience, it is reasonable to hypothesise that psychotic experiences emerging in the context of war are particularly likely to involve themes of threat and persecution. For this reason, this article has placed particular emphasis on understanding the mechanisms underlying paranoia and on interventions that aim to reduce perceived threat while fostering a greater sense of safety. This review aims to provide mental health professionals with practical frameworks and clinical tools for working with psychosis while fostering dialogue, meaning, and curiosity within psychotic experience. Shifting the therapeutic perspective—from an exclusive focus on symptoms and symptom reduction toward an appreciation of the whole person and the unique context in which their experiences arise—may lead to a deeper understanding of those we work with and support them in building meaningful and fulfilling lives, even in the presence of enduring and complex psychotic experiences.

This article was originally published in Hebrew. Read the original publication.