The Decider Skills for Self Help online self help course

Psychosis Self Help

Self help guide for problems associated with psychosis (delusions and paranoia), using effective CBT strategies. Make sense of the problem, then learn how to make positive changes

Cognitive Behaviour Therapy will not cure or treat the underlying cause of the delusions or hallucinations (most commonly voices), but can help you deal with the distress associated with them.

This self help guide assumes that you are already receiving treatment from an appropriate mental health professional or doctor. If you are experiencing symptoms such as hearing voices or others are concerned about your responses to what might be normal events as a result of your fixed, false and unreasonable beliefs, then you should seek the help initially of your GP who will refer you to a psychiatrist for appropriate treatment.

In this context, "paranoia" is the false and fixed belief that others are persecuting you or trying to harm or kill you, rather than an anxiety about others thinking critically of you, for example at a social gathering.

As explained on this page, CBT looks at the links between our thoughts, our feelings and our behaviours. Our feelings result from the way we interpret and try to make sense of our world, which is often a result of our culture, education and our experiences. In psychosis, this process doesn't work quite the way it normally does, and we can experience sensations that other people don't (hallucinations) and have fixed, false beliefs (delusions) about what are otherwise seemingly normal events, causing much distress. These voices or delusions can often be related to our past.

We often use the acronym "ABC" to look at this process.

A Activating Event (or voice)
B Belief about the event (or voice)
C Consequence - feelings and behaviours

For instance, a paranoid delusion - the distressing meaning we give to a situation - might be:

My cousin is trying to kill me!

This came about in the following way:

It wasn't the event itself which causes the distress, but the belief or meaning we give the event, the way we make sense of it. Just as in CBT for depression and anxiety, we can challenge and learn to think differently about our thoughts.

In the case of distressing voices, then it's the belief we have about, or meaning we give the voices, that causes the distress. This might include how much we believe that the voice speaker is able to control us, how powerful it is, how harmful they might be, who it is, how many of them there are, and what we believe about what the voice actually says.

Example of Distressing Voice resulting in self-harm:

If the voice hearer was able to challenge or think differently about the voice, or about the belief they have or meaning they give the voice, then they are less likely to feel distressed, and therefore much less likely to self-harm.

First Steps

The first step is to start to become aware and notice what's happening at those times - just as in CBT for depression and anxiety, we can start to notice our thoughts, emotions, physical sensations and behaviours using the 5 Aspects or the ABC Worksheets below. Initially it helps to write these down after the event, when the distressed has mostly passed. Later, as you get more used to it, you will start to notice these internal experiences at the time that they happen.

Example 5 Aspects formulation of Paranoid Delusion:

It helps to get someone on side, who can help you with this - perhaps a therapist, but also a close family member or friend.

5 Aspects For Voices PDF
ABC Worksheet For Voices PDF
5 Aspects For Delusions / Paranoia PDF
ABC Worksheet For Delusions / Paranoia PDF
Personal Recovery & Maintenance Plan For Psychosis PDF

Identifying Triggers

Notice when the voices are worse - louder, more frequent, when you think you're less able to cope and feel more distressed by them.

Notice the situations in which you feel paranoid, or are more likely to feel distressed. Where, when, who with, what is it about those times?

Use the Early Warning Signs Form PDF to help you identify when you're becoming more vulnerable or unwell.

Doing things differently

If distressed by voices:

Can you do anything differently at those times when you're likely to feel more distressed by voices?
For instance: Focus your attention on something other than the voices (see mindfulness page) - listen attentively to music (use headphones?), engage in an absorbing activity, be with others rather than alone, mindful breathing, focus on the environment around you, talk to someone,
Talk into a mobile phone if you need to talk back to voices
Teach the voice to tone down, or visualise an internal volume control (turn the dial down a little at a time)
Give the voices a job to do elsewhere for a few minutes or hours

Thinking differently

STOPP! Pause, take a breath, don't react automatically
Ask yourself:
What am I reacting to?
Is this fact or opinion?
The "is it real" test: 1. Is it possible? 2. Check the evidence (e.g. check reaction of others, ask someone etc)
Is it a voice or other sensory experience?
What meaning am I giving this experience or thought?
What goes through my mind when the voice says that?
What do I believe about that?
Am I agreeing with the voice? Totally?
Does that thought or belief fit with my own inner beliefs and morals?
How am I making sense of this?
What is it that I think is going to happen here?
What's the worst (and best) that could happen? What's most likely to happen?
Am I getting things out of proportion?
What's the bigger picture?
How important is this really? How important will it be in 6 months time?
Am I overestimating the danger?
Am I underestimating my ability to cope?
How much control does this voice or belief have over me?
Am I mind-reading what others might be thinking?
Am I believing I can predict the future?
Is there another way of looking at this?
What advice would I give someone else in this situation?
Am I putting more pressure on myself?
Just because I feel bad, doesn't mean things really are bad.
Use Wise Mind
What do I want or need from this person or situation? What do they want or need from me? Is there a compromise?
What would be the consequences of responding the way I usually do?
How would that help?
Is there another way of dealing with this? What would be the most helpful and effective action to take? (for me, for the situation, for the other person)