4.3.5 - CBT and family therapy for schizophrenia
Psychological therapies can help people manage experiences and reduce relapse without claiming that symptoms are simply imagined. You will examine how CBT for psychosis tests interpretations and develops coping strategies, and how family therapy changes communication, stress and expressed emotion. Evidence supports evaluation of effectiveness, suitability, time, consent and the value of combining therapy with other forms of support.
Aims of psychological therapy
AQA names two psychological therapies for this specification point: cognitive behaviour therapy and family therapy. Both are used in the treatment of schizophrenia, but the word "treatment" needs careful handling. These therapies do not claim to cure schizophrenia or remove all hallucinations, delusions or negative symptoms. They aim to reduce distress, improve coping and functioning, reduce relapse risk and support recovery alongside wider care.
Cognitive behaviour therapy for psychosis
Cognitive behaviour therapy for psychosis, often shortened to CBTp, is a collaborative talking therapy that helps a person link thoughts, feelings, behaviours and psychotic experiences, then test and modify distressing interpretations and coping responses.
For example, a person may hear a voice and interpret it as an all-powerful external threat. CBTp would not simply tell the person "that is not real". A clinically careful therapist validates that the experience is frightening, explores evidence for different interpretations, and helps the person develop safer coping strategies. The aim is often to make the voice less distressing or less controlling, even if the experience does not disappear.
Family therapy
Family therapy is a psychological intervention involving the person with schizophrenia and some or all close family members or carers, with the aim of improving understanding, communication, problem-solving and emotional climate.
Family therapy matters because schizophrenia is lived in a social context. Families often provide practical and emotional support, but stress, misunderstanding and conflict can increase the pressure on the person. Therapy therefore works with the family system rather than treating the family as "to blame".
In UK clinical guidance, CBT and family intervention are usually recommended with antipsychotic medication, not as simple replacements for it. That is an interactionist assumption: biological treatment may reduce symptom intensity, while psychological treatment helps with meaning, coping, relationships and relapse prevention.
For AQA, keep three routes clear:
| Assessment route | What to show in this topic |
|---|---|
| AO1 | Accurate aims and processes of CBTp and family therapy. |
| AO2 | Apply the processes to a person or family scenario. |
| AO3 | Evaluate effectiveness, evidence quality, practicality, ethics and comparison. |
CBT for psychosis
The central aim of CBTp is to help the person make sense of psychotic experiences and respond to them in less distressing, less disabling ways. It is especially relevant to positive symptoms such as hallucinations and delusions, but it can also support functioning, motivation and coping with secondary anxiety or depression.
Normalisation
Normalisation means helping a person understand that unusual experiences can be placed on a continuum with ordinary mental processes, so the experience feels less alien, shameful or frightening.
A typical CBTp process includes the following stages.
| Stage | What happens | Why it helps |
|---|---|---|
| Engagement and assessment | The therapist builds trust and identifies the experiences causing most distress. | A person may be suspicious or frightened, so collaboration is essential. |
| Formulation | The therapist and client map links between triggers, beliefs, emotions, behaviours and symptoms. | The problem becomes understandable rather than random or overwhelming. |
| Normalisation and psychoeducation | The person learns that voice-hearing or unusual beliefs can occur in psychosis and can be managed. | This may reduce fear, self-blame and stigma. |
| Reality testing | The person and therapist gently examine evidence for and against a belief. | This can weaken the certainty or threat attached to a delusion. |
| Coping strategies | The person practises alternatives such as attention-switching, challenging appraisals, relaxation, behavioural experiments or planned routines. | The person gains practical control over distress and daily functioning. |
| Relapse prevention | The person identifies early warning signs and helpful responses. | This can support longer-term recovery and continuity of care. |
The cognitive part of CBTp targets the meaning attached to symptoms. If Kai believes a voice proves that neighbours are spying on him, the distress may come partly from the interpretation "I am in danger". The behavioural part targets responses that maintain the problem. If Kai stops leaving the house, he has fewer chances to test alternative explanations, so anxiety may increase.
CBTp is therefore not a debate club in which the therapist wins an argument. It is a guided investigation. A good answer should use verbs such as identify, monitor, re-evaluate, test, normalise, cope and reduce distress.
Worked application: changing a threatening interpretation
Alex hears a voice and believes, "It controls whether I can leave the house." A formulation links hearing the voice to that threat belief, anxiety and staying indoors. Staying in may bring immediate relief but prevent Alex discovering whether the feared prediction is accurate, maintaining avoidance.
The therapist and Alex might agree on a safe, manageable test of a specific prediction, such as a brief supported walk, and review what happened and how anxiety changed. Coping methods can make the test manageable. This is collaborative testing of a belief's power, rather than arguing that Alex did not hear anything. Success might be less distress and greater freedom to act even if the voice is still heard; symptom frequency and functioning are separate outcomes.
Family therapy
Family therapy aims to reduce stress around the person with schizophrenia and improve the family's ability to support recovery. It is often called family intervention in clinical guidance because it may include psychoeducation, communication work and problem-solving rather than one single style of therapy.
Expressed emotion
Expressed emotion is the emotional climate shown by relatives or carers, especially levels of criticism, hostility and emotional over-involvement. High expressed emotion is associated with higher relapse risk in schizophrenia.
High expressed emotion does not mean relatives are cruel or responsible for causing schizophrenia. It often develops because families are frightened, exhausted, confused or trying too hard to help. The therapy goal is to reduce unhelpful interaction patterns without blaming the family.
Key processes include:
| Process | What the therapist does | Example |
|---|---|---|
| Psychoeducation | Gives accurate information about symptoms, medication, relapse signs and recovery. | A parent learns that avolition can look like laziness but is a negative symptom. |
| Reducing expressed emotion | Identifies criticism, hostility or over-involvement and replaces them with calmer responses. | A family practises making requests without repeated accusations. |
| Communication training | Teaches listening, turn-taking and clear expression of concerns. | Family members practise saying what they need without escalating conflict. |
| Problem-solving | Helps the family agree practical steps for recurring difficulties. | The family makes a plan for sleep disruption, appointments or medication reminders. |
| Crisis and relapse planning | Identifies early warning signs and what each person should do. | The family agrees when to contact the care team if symptoms intensify. |
| Support for carers | Recognises the pressure on relatives and protects their wellbeing. | A carer is helped to maintain work, friendships and rest. |
NICE guidance describes family intervention as including the person with psychosis or schizophrenia if practical, taking place over 3 months to 1 year, and including at least 10 planned sessions. This tells you something important for AO1: family therapy is not a single advice meeting. It is a structured programme.
AO2 often comes from spotting family processes in a scenario. If a father repeatedly says, "You are choosing to stay in bed", psychoeducation may help him understand avolition. If a sister checks on the person every few minutes, therapy may work on emotional over-involvement and independence. If everyone avoids discussing warning signs, relapse planning may be needed.
Worked application: from criticism to a practical plan
A carer says, "You never make an effort to get up." Psychoeducation first considers whether avolition, low mood or medication effects help explain the difficulty. Communication work changes the accusation into a clear, achievable request agreed with the person. Problem-solving then identifies a small practical step and who can help, without turning support into repeated surveillance. Relapse planning addresses a different question: what changes would prompt contact with the care team?
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