Medication resistant psychosis: how many CBT sessions might be needed for recovery? A case report with psychodynamic commentary

BackgroundWhen clinicians adopt the standard 16–26 session maximum suggested by CBTp efficacy research, clients with long-term medication resistant psychosis may receive an inadequate dose of therapy. Building engagement and trust can take significantly longer for clients who have been given a stigmatizing medical explanation for their difficulties.MethodsWe present a case study of successful long-term CBTp consisting of 200 sessions over a 6-year period. Supervision aided the recovery process over the last 2 years of therapy.ResultsA client with a 30-year history of medication resistant persecutory delusions, voices, stigma and prominent negative symptoms gradually formed a working alliance with the therapist. A CBT formulation emphasizing activating the adaptive mode led to later targeted work to reduce distress and social avoidance and address underlying trauma. Social recovery was achieved with increased independence and enhanced creativity. A commentary is provided by a senior clinician from a psychodynamic perspective.DiscussionClients with long-term medication resistant psychosis often need an increased number of CBT sessions but can still recover. Ongoing supportive supervision prevents early discharge and a failure to achieve a recovery trajectory. We should not accept that medication resistant clients are CBT resistant following a brief course of therapy.