I vividly remember my first experience providing psychotherapy for a patient with psychotic symptoms. In fact, not only was this patient my first with psychosis, but they were my first individual therapy patient ever. As a practicum student at a partial hospitalization program, I was caught off-guard when my patient endorsed auditory hallucinations during an initial intake. Thoughts and doubts such as “I don’t know what I’m doing” and “Could I make my client’s symptoms worse?” flooded my mind.
Ultimately, it was a rewarding experience, and I enjoyed bearing witness to my client’s growth, impressive resilience and resolve. However, there are many things I wish I had known ahead of this first experience. Therefore, this article aims to use my experience as a reference point to provide a brief snapshot of important domains to consider when treating psychosis for the first time.
Tips for Differential Diagnosis
Become Familiar with Psychotic-Spectrum Disorders
Knowing the differences between psychotic-spectrum disorders will lend itself to appropriate treatment goals. Moreover, there are slight yet essential differences between psychotic spectrum disorders per DSM-5 criteria . For instance, you may ask: Are schizophrenia and schizoaffective disorders different from one another? What about schizophrenia and schizophreniform disorders? To elucidate this idea, a diagnosis of schizoaffective disorder would require greater attention to mood symptoms than other psychotic-spectrum disorders.
Know the Relationships Between Medical Diagnoses and Psychotic Disorders
Numerous medical disorders include symptoms of psychosis as associated features. This helpful Time2Track article provides a summary of psychiatric symptoms caused by medical disorders. In general, psychotic features may accompany the following medical disorders and conditions: Huntington’s Disease, epilepsy, hyperthyroidism, hypothyroidism, metabolic diseases, and migraines, to name a few .
Advocating for your client to receive thorough medical screenings to rule out these conditions will ensure that they receive appropriate treatment. Psychiatric disorders such as PTSD, mood disorders, OCD, anorexia nervosa, and body dysmorphic disorder can have associated psychotic features .
Be Aware of the Influence of Setting
It’s easy to allow your setting to lead you astray when conceptualizing and diagnosing psychosis. For instance, perhaps you are working within a medical system, and your clinic received a referral from a neurology clinic that believes that their patient is experiencing psychogenic seizures. The clinic reported that the patient is experiencing episodes during which they displayed decreased responsiveness to external stimuli.
Within the context of a neurology clinic, this seems to be a fair assumption for the practitioners to make. However, unresponsiveness to external stimuli is a feature shared with both pseudoseizures and negativism in catatonia . Therefore, it is essential to remain open-minded and aware that setting (in this instance, a neurology clinic) can unduly influence the diagnosis process.
It may come as no surprise that developing and maintaining a collaborative approach to treating patients with psychosis is essential. While this is a crucial skill for work with all psychotherapy clients, it is vital for clients with psychosis. Here’s why: hardship frequently accompanies psychosis, including enduring stigma, trauma, unemployment, and prior discrimination from healthcare providers .
These challenges can lead to a loss of both actual and perceived autonomy. Therefore, it’s our duty as psychologists and psychotherapists to establish collaborative relationships in which clients have a say in their treatment to support and reaffirm individuals’ right to autonomous decision-making and self-determination.
Build From Your Knowledge Base
Developing a cohesive theoretical orientation settled within a framework of evidence-based practice can be dizzying on its own. Using cutting-edge research to adapt your approach to treating specific DSM classifications of disorders, such as psychosis, can add an entirely new dimension to this challenge.
Taking inventory of what modalities you already use to treat clients with more common presenting concerns, such as anxiety and depression, can help with this dilemma. You can then use this as scaffolding to begin developing your treatment approach to clients with psychosis. For instance, there is ample research supporting the use of CBT and Acceptance and Commitment Therapy (ACT) for psychosis. However, it’s important to become educated on adaptations of these modalities while treating psychosis. The treatment approach may look different when addressing psychotic symptoms than addressing anxiety and depression symptoms.
Keep the Recovery Model in Mind
Before thinking about specific treatment models, it’s important to think about recovery broadly. The recovery model acts as a guidepost for therapy with clients with psychosis, giving us multiple avenues to explore as we move through treatment or when something isn’t clicking. The Substance Abuse and Mental Health Services Administration (SAMHSA) defines recovery as: “a process of change through which people improve their health and wellness, live self- directed lives, and strive to reach their full potential.” . Accordingly, SAMHSA outlines four dimensions of recovery: health (living in a way that supports the management of illness and reinforces overall well-being); home (securing stable housing); purpose (creating a life worth living) and community (relationships and social connections that are meaningful and supportive).
Taking these dimensions into consideration while treating a client with psychosis will facilitate holistic care and recovery in the therapy room, and more importantly, real-world settings. For instance, you may develop a solid therapeutic alliance with your client and experience success while implementing social skills techniques.
However, if the social skills are not translating to significant relationships in your client’s life, it is clear that something is not working. At this point, it would be time to go back to the drawing board and take a look at which dimension of recovery is not represented adequately. In this example, you could consider what steps you should take to facilitate the translation of in-session social skills to the community domain (friendships), which may, in turn, impact the purpose domain in terms of fostering a life worth living.
Evidenced-based modalities for treating psychosis include assertive community treatment, cognitive-behavioral approaches, family psychoeducation, social skills training, supported employment and cognitive remediation . For this article, I will be focusing on cognitive-behavioral approaches (and their successors) that can be applied in various settings where traditional, individual psychotherapy is a significant focal point of treatment.
For years now, cognitive-behavioral approaches have been a frontline treatment for many disorders. In terms of conceptualization of psychosis, Aaron Beck viewed positive symptoms as thoughts that have been externalized or viewed as coming from an outside source instead of being identified as an internal experience . A core component of CBT for psychosis is cognitive restructuring, which helps clients engage in reality testing of the distorted thinking assumed to underly delusions .
For instance, if a client believes that someone is poisoning them, this thought would be challenged. Additionally, the client and therapist would work together to develop alternatives as to why, for example, their milk might taste strange.
Acceptance and Commitment Therapy (ACT) for Psychosis
ACT has gained ground in recent years, and ACT theorists view thoughts as fundamentally subjective and uncontrollable . Thus, acceptance of experience is a primary objective. Furthermore, it’s believed that behavior should result from values. In terms of treating psychosis, cognitive fusion (or attachment) to delusions and hallucinations is a focal point. In other words, distress comes from the belief that a delusion or hallucination is reality, rather than the content of the delusion or hallucination itself.
Instead of challenging whether a delusion or hallucination is true or not, a client is encouraged to accept (rather than avoid) the thought as merely a thought and focus on acting in alignment with their values . For example, with a client experiencing the aforementioned belief that they are being poisoned, a treatment objective might be to accept this as merely a thought rather than engage in behavior aimed towards questioning or trying to change it. Furthermore, treatment would hone in on the client’s valuing system and focus on pursuing a goal, such as finishing a college degree.
Recovery-Oriented Cognitive Therapy
In Recovery-Oriented Cognitive Therapy (CT-R), the primary focus is assisting your patient in activating and maintaining the adaptive mode, which is conceptualized as optimal functioning as a result of participating in preferred and meaningful activities . The cognitive model is woven into the framework of CT-R with the goal that when a person is engaged in meaningful activities, positive cognition will follow. As is broadcasted in the title, recovery, rather than symptom reduction, is the focus of CT-R.
How Stigma Can Impact Practice
Last but certainly not least, stigma toward serious mental illness can negatively impact our practice. Countertransference in the therapy room is something that is sufficiently covered in most doctoral training programs. For most students, hours are spent on reflection pieces to ensure that we have a handle on how our emotional reactions impact the work we do. However, many programs fail to incorporate the added element of social stigma that is part and parcel of serious mental illnesses such as psychosis.
Therefore, it is paramount for clinicians working with a client with psychosis to remain aware of how internalized social stigma may be impacting their work. This can help therapists avoid the stigma of serious mental illness sneaking into the therapy room, and taking up unwelcomed space. To self-assess how stigma may affect your practice, I recommend considering the following questions:
- What messages have you been exposed to about psychotic disorders?
- In what ways have you been impacted by these messages?
- As you begin or prepare to treat clients with psychosis, what thoughts and feelings arise?
Treating psychosis for the first time can feel daunting. Entering your first session with a roadmap for diagnosis, treatment, and combating stigma will set you and your clients up for a successful journey.
 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5.
 Wright, N., Turkington, D., Kelly, O., Davies, D., Jacobs, A., & Hopton, J. (2014). Treating psychosis: a clinician’s guide to integrating Acceptance & Commitment Therapy, compassion- focused therapy, & mindfulness approaches within the cognitive behavioral therapy tradition. New Harbinger Productions, Inc.
 American Psychological Association & Jansen, M.A. (2014). Recovery to practice initiative curriculum: reframing psychology for the emerging health care environment. Washington D.C.: American Psychological Association.
 Substance Abuse and Mental Health Services Administration. (2020, April 23). Recovery and Recovery Support. https://www.samhsa.gov/find-help/recovery
 Beck, A.T., Rector, N.A., Stolar, N., & Grant, P. (2009). Schizophrenia: Cognitive theory, research, and therapy. The Guilford Press.
 Hagen, R., Turkington, D., Berge, T., & Grawe, R.W. (2011). CBT for Psychosis: A Symptom based approach. Routledge, Taylor & Francis Group.
 Morris, E.M., Johns, L.C., & Oliver, J.E. (2013). Acceptance and Commitment Therapy and mindfulness for psychosis. John Wiley & Sons, Ltd.
 Beck, A.T., Grant, P., Inverso, E., Brinen, A.P., & Perivoliotis, D. (2021). Recovery-Oriented cognitive therapy for serious mental health conditions. The Guilford Press.