CBT for psychosis in a psychoanalytic frame

Supportive psychodynamic psychotherapy for psychosis

The UK National Institute for Health and Care Excellence guidance suggests that psychodynamic principles may be used to understand the experiences of people with psychosis. In this article we consider the application of psychodynamic principles in psychotherapy for psychosis, focusing on one particular model: supportive psychodynamic psychotherapy (SPP). We describe this approach with a detailed fictitious case example and discuss how SPP has developed through significant modifications of classical psychoanalytic therapy and the evidence base for it. We consider its overlap with cognitive–behavioural therapy, its advantages and disadvantages, and the arguments for making SPP available as a treatment option in services for psychosis.

Avatar therapy for persecutory auditory hallucinations: What is it and how does it work?

We have developed a novel therapy based on a computer program, which enables the patient to create an avatar of the entity, human or non-human, which they believe is persecuting them. The therapist encourages the patient to enter into a dialogue with their avatar, and is able to use the program to change the avatar so that it comes under the patient's control over the course of six 30-min sessions and alters from being abusive to becoming friendly and supportive. The therapy was evaluated in a randomised controlled trial with a partial crossover design. One group went straight into the therapy arm: "immediate therapy". The other continued with standard clinical care for 7 weeks then crossed over into Avatar therapy: "delayed therapy". There was a significant reduction in the frequency and intensity of the voices and in their omnipotence and malevolence. Several individuals had a dramatic response, their voices ceasing completely after a few sessions of the therapy. The average effect size of the therapy was 0.8. We discuss the possible psychological mechanisms for the success of Avatar therapy and the implications for the origins of persecutory voices.