CBT for Psychosis: What the Evidence Shows in Schizophrenia

Cognitive behavioral therapy for psychosis (CBTp) is a structured talk therapy that is usually studied as an addition to antipsychotic medication. A 2014 meta-analysis found a pooled effect size of -0.33 on overall symptoms in 34 studies, -0.25 on positive symptoms in 33 studies, and -0.13 on negative symptoms in 34 studies. The authors placed the effect in the "small" range.¹

Masking of the symptom raters moderated the effect size for overall symptoms (-0.62 versus -0.15) and for positive symptoms (-0.57 versus -0.08).¹ One of the authors later identified the smaller figures as the blind studies, 20 of overall symptoms and 20 of positive symptoms, and noted that the second was non-significant.²

CBT added to medication has a small effect on symptoms

A 2018 network meta-analysis covered 53 randomized trials and 4,068 participants who received a psychological treatment as an add-on to antipsychotics. CBT, studied in 40 of the trials, reduced positive symptoms more than treatment as usual, with a standardized mean difference of -0.30 (95% CI -0.45 to -0.14). The authors rated confidence in the estimates from moderate to very low.³

Voices, delusions, and negative symptoms

A meta-analysis of individually tailored CBT reported effect sizes of 0.44 for hallucinations and 0.36 for delusions, which the authors called modest. In blinded studies the figures were 0.46 and 0.24.⁴ For negative symptoms, a meta-analysis of 30 trials in 2,312 patients found a pooled effect of 0.093, not statistically significant, in studies where negative symptoms were a secondary outcome.⁵

Functioning improved at the end of the trial and was not significant at follow-up

A 2018 meta-analysis of 36 randomized trials found a small effect on functioning at the end of the trial (0.25, 95% CI 0.14 to 0.33). At follow-up the effect was 0.10 and non-significant. A small benefit for distress (0.37) became nonsignificant after adjustment for possible publication bias, and CBTp showed no benefit for quality of life (0.04).⁶

A 2022 overview of systematic reviews listed CBT among the interventions that improved quality of life.⁷ On long-term relapse, a Cochrane review of 60 trials found no clear difference between CBT added to standard care and standard care alone (risk ratio 0.78, 95% CI 0.61 to 1.00, low-quality evidence), while a 2021 network meta-analysis found that CBT reduced relapse more than treatment as usual at 1 year (odds ratio 0.45, 95% CI 0.27 to 0.75).^{8, 9}

CBT without antipsychotic medication

A 2014 trial enrolled 74 people with schizophrenia spectrum disorders who had already chosen not to take antipsychotics. They were randomized to cognitive therapy plus treatment as usual or to treatment as usual alone. PANSS total scores were consistently lower with cognitive therapy across assessments through month 18, with an estimated between-group effect size of -6.52 (95% CI -10.79 to -2.25). The trial had no antipsychotic arm, and the authors called for a larger, definitive trial.¹⁰

A head-to-head comparison is a 2018 pilot whose primary outcome was feasibility. It assigned 75 people to CBT (26), antipsychotics (24), or both (25). PANSS total scores were significantly lower with the combination than with CBT alone (-5.65, p=0.019). CBT and antipsychotics did not differ significantly from each other (-1.13, p=0.637), and 11 of the 49 people randomized to antipsychotics were not prescribed a regular one.¹¹ A 2026 pooled analysis of that pilot and a second randomized trial, 136 participants in all, found no evidence of a difference in PANSS total score between CBTp alone and antipsychotics alone at 6 months, and found evidence favoring the combination over antipsychotics alone.¹²

These trials are small, and they can't establish that therapy alone performs as well as medication. The UK guideline, in a recommendation tagged 2014, reads: "Advise people who want to try psychological interventions alone that these are more effective when delivered in conjunction with antipsychotic medication." It then calls for a review of treatment options, including introducing antipsychotic medication, within 1 month or less.¹³ Whether to take, change, or stop an antipsychotic is decided with the prescriber. I've written separately about stopping antipsychotics.

CBT when clozapine hasn't worked

The FOCUS trial randomized 487 people with clozapine-resistant schizophrenia to CBT plus treatment as usual (242) or treatment as usual alone (245). The primary outcome, PANSS total score at 21 months, showed no difference (mean difference -0.89, 95% CI -3.32 to 1.55; p=0.48). At the end of treatment at 9 months the difference was -2.40 points (p=0.049), which the authors described as "statistically, though not clinically, significant."¹⁴

The authors concluded that the results "do not support a recommendation to routinely offer CBT to all people who meet criteria for clozapine-resistant schizophrenia", while allowing that an individual trial might be indicated for some.¹⁴ Other options are covered on the page about clozapine not working.

What the guidelines say

In the UK, the National Institute for Health and Care Excellence (NICE) guideline reads "Offer CBT to all people with psychosis or schizophrenia" and specifies delivery "on a one-to-one basis over at least 16 planned sessions". Both recommendations carry a 2009 tag, which predates the meta-analyses above.¹³

In the United States, the 2009 Schizophrenia PORT recommendations state that people with persistent psychotic symptoms while receiving adequate pharmacotherapy "should be offered adjunctive cognitive behaviorally oriented psychotherapy to reduce the severity of symptoms", in a group or an individual format lasting approximately 4 to 9 months.¹⁵

Finding CBT for psychosis in the United States

A 2019 paper stated: "Based on recent estimates, only 0.3% of individuals with a primary psychotic disorder are able to access this treatment in the United States." Its abstract gives no primary reference or year for that estimate.¹⁶

When looking for a therapist, it's reasonable to ask whether they have specific training in CBT for psychosis, whether they follow a treatment manual, and how they'll coordinate with the prescriber.

Limitations of the evidence

This evidence has limitations. First, the 2014 meta-analysis found smaller effects in blind studies, and the network meta-analysis rated its confidence from moderate to very low. Second, the comparisons with antipsychotics are small trials, and the authors of the network meta-analysis found adverse events very poorly reported in the trials. Nevertheless, the meta-analyses of overall and positive symptoms point the same way: CBT added to medication has a small effect.^{1, 3, 12}

CBT for psychosis is an addition to antipsychotic treatment for people with persistent symptoms, and the reasonable expectation is a modest improvement. Medication decisions stay with the patient and the prescriber.

In a crisis: call or text 988, or go to the nearest emergency department. A first episode of psychosis belongs in a hospital-based or coordinated specialty care program.

I start and manage clozapine in an outpatient practice in Chelsea, Manhattan. Details are on the schizophrenia care in NYC page. Clozapine should not be stopped, skipped, or restarted without the prescriber. This page is general information and does not replace an evaluation.

Related: Schizophrenia and psychosis treatment guide · When to start clozapine · Clozapine blood tests after the REMS ended · Clozapine side effects · Missed clozapine doses · Clozapine and suicide risk · Cannabis and psychosis · Schizoaffective vs schizophrenia · Cobenfy vs clozapine · Postpartum psychosis · Injections vs pills · Stimulants and psychosis · Drug-induced psychosis · Clozapine levels · Clozapine myocarditis · Cannabis after psychosis · Clozapine constipation · Work and school · Clozapine drooling · Early signs in teens · Clozapine weight gain · Genetic and family risk · Who can prescribe clozapine · Schizophrenia and violence · Clozapine in teenagers · Sleepiness, bedwetting, heart rate · When clozapine isn't enough · Clozapine interactions · Benign ethnic neutropenia · Clozapine off-label uses · Starting clozapine · Clozapine and pneumonia · Clozapine seizures · Clozapine in pregnancy · Clozapine rechallenge · Relative refuses treatment · Late-onset schizophrenia · Negative symptoms · First-episode psychosis · Tardive dyskinesia · Stopping antipsychotics · Schizophrenia life expectancy · Key clozapine studies