Cognitive behaviour therapy | AQA A-Level Psychology Revision

For 7182 specification, first teach in September 2025

AQA A-Level Psychology | Free Revision Notes

Estimated study time: 60 minutes

Cognitive behaviour therapy helps people with schizophrenia understand connections between their thoughts, emotions and behaviour. These Cognitive behaviour therapy A-Level Psychology revision notes explain how a therapist may examine delusional beliefs, explore interpretations of voices and develop practical strategies for managing distress.

CBT does not simply tell a person that their experiences are untrue. Effective therapy is collaborative and aims to reduce distress, improve functioning and increase the person’s sense of control. The current AQA specification requires cognitive behaviour therapy as a treatment for schizophrenia.

Learning Objectives 🎯

By the end of this revision page, you should be able to:

• Explain how CBT is used to treat schizophrenia.

• Explain cognitive restructuring and reality testing.

• Explain how beliefs, voices and interpretations may be examined.

• Describe coping strategies used within CBT.

• Apply CBT to unfamiliar scenarios involving hallucinations and delusions.

• Evaluate the effectiveness and appropriateness of CBT.

Revision Notes 📚

Cognitive behaviour therapy A-Level Psychology revision overview

Cognitive behaviour therapy, usually abbreviated to CBT, is a psychological treatment that examines connections between:

• Thoughts.

• Beliefs.

• Interpretations.

• Emotions.

• Behaviour.

A person’s emotional and behavioural response to an experience depends partly on how they interpret it.

For example:

A person notices two strangers looking towards them.

One interpretation might be:

“They happened to look in my direction.”

Another interpretation might be:

“They have been sent to monitor me.”

The second interpretation may produce:

• Fear.

• Suspicion.

• Avoidance.

• Safety behaviours.

• Increased attention to possible threats.

CBT helps the person identify this pattern and consider whether alternative interpretations are possible.

AQA mark schemes describe CBT as helping patients identify and manage intrusive or delusional thoughts, develop more rational interpretations and learn strategies for mastering distressing thoughts.

What are the aims of CBT?

CBT may aim to:

• Help the person understand their thoughts and experiences.

• Identify beliefs connected with distress.

• Examine evidence supporting and challenging those beliefs.

• Develop alternative interpretations.

• Reduce fear associated with hallucinations or delusions.

• Develop coping strategies.

• Increase social and everyday activity.

• Improve the person’s sense of control.

• Reduce the effect symptoms have on daily life.

CBT is not necessarily a cure

CBT may not completely remove:

• Voices.

• Unusual beliefs.

• Genetic vulnerability.

• Altered dopamine functioning.

• Every negative symptom.

Instead, it may help the person:

• Feel less frightened.

• Question threatening interpretations.

• Respond differently to voices.

• Reduce avoidance.

• Continue ordinary activities.

• Cope more effectively.

The distinction is important:

A symptom may continue, but its emotional and behavioural impact may become less severe.

The cognitive basis of CBT

CBT is linked with dysfunctional thought processing and symptom formation [Cognitive explanations].

Cognitive explanations propose that schizophrenia may involve difficulties:

• Recognising thoughts as self-generated.

• Distinguishing internal experiences from external events.

• Interpreting ambiguous situations.

• Monitoring thoughts and actions.

• Considering alternative explanations.

CBT attempts to improve how the person understands and responds to these experiences.

Explanation and treatment

Cognitive explanation	Cognitive behaviour therapy
Explains how dysfunctional processing may contribute to symptoms	Attempts to change interpretations and responses
Includes source-monitoring failure	Explores possible origins of voices
Includes maladaptive interpretations	Develops alternative interpretations
Includes difficulty monitoring thoughts	Increases awareness of thinking
Explains hallucinations and delusions	Helps manage hallucinations and delusions

Do not confuse the reason symptoms may occur with the procedure used to treat them.

The therapist-client relationship

Collaboration

Effective CBT is collaborative.

The therapist and client work together to examine:

• What the person experiences.

• What the experience means to them.

• How strongly they hold a belief.

• What emotions result.

• What behaviour follows.

• Which strategies might reduce distress.

The therapist should not simply announce:

“Your belief is wrong.”

Direct confrontation may:

• Damage trust.

• Increase defensiveness.

• Strengthen suspicion.

• Lead the person to withdraw from therapy.

• Confirm a belief that professionals are hostile.

Instead, the therapist may ask careful questions that allow the person to examine the belief themselves.

Respecting the person’s experience

A person who hears a voice genuinely experiences it.

CBT should not treat the person as:

• Pretending.

• Being deliberately irrational.

• Choosing their symptoms.

• Responsible for becoming unwell.

The therapist can accept that the experience is real and distressing for the person while exploring different explanations for its origin and meaning.

Building trust

A trusting relationship is particularly important when a person experiences:

• Persecutory delusions.

• Suspicion of professionals.

• Fear of being controlled.

• Voices warning them not to trust others.

Therapy may initially focus on:

• Listening.

• Understanding the person’s concerns.

• Agreeing shared goals.

• Reducing immediate distress.

Challenging beliefs too quickly may be counterproductive.

Assessment and cognitive formulation

Initial assessment

The therapist gathers information about:

• Hallucinations.

• Delusions.

• Emotions.

• Behaviour.

• Triggers.

• Relationships.

• Stress.

• Coping strategies.

• Current medication.

• Effects on daily life.

The aim is not merely to count symptoms.

The therapist needs to understand:

how the person interprets the experience and what happens as a result

Cognitive formulation

A cognitive formulation is an individual explanation of how a person’s experiences, beliefs, emotions and behaviour connect.

For example:

hears a voice → believes the voice has unlimited power → feels terrified → obeys every command → becomes more focused on the voice

The formulation identifies possible points where therapy can help.

The therapist might work on:

• The belief that the voice is all-powerful.

• The fear generated by that belief.

• The behaviour of automatically obeying.

• The person’s attention to the voice.

• Alternative coping responses.

Individualised treatment

Two people may hear similar voices but interpret them differently.

Person A

“The voice is irritating, but it cannot hurt me.”

Person B

“The voice is an all-powerful being that will punish me.”

Person B is likely to experience greater fear and disruption.

CBT therefore focuses not only on the presence of a voice but also on:

• Meaning.

• Power.

• Threat.

• Control.

• The person’s response.

The thoughts-emotions-behaviour link

CBT helps the client identify how an interpretation affects emotion and behaviour.

A simplified sequence is:

event or experience → interpretation → emotional consequence → behavioural response

Example

Experience:

A care worker arrives unexpectedly.

Belief:

“They have come to harm me.”

Emotion:

Fear.

Behaviour:

Locking doors and refusing contact.

The therapist may help the person see that the fear and avoidance follow from the interpretation rather than simply from the care worker’s arrival.

AQA’s November 2020 mark scheme credited explaining links between a persecutory belief, fear and behaviour such as locking doors.

Identifying beliefs

The first cognitive step is often to identify the belief producing distress.

The therapist may ask:

• What went through your mind?

• What did you think the event meant?

• Why did the voice feel threatening?

• What did you expect would happen?

• How certain were you?

• What did you do next?

Example

Hannah refuses food because she believes staff have poisoned it.

The relevant belief is not simply:

“The food tastes unusual.”

It is:

“The staff deliberately poisoned the food to harm me.”

The therapist can then examine:

• The evidence Hannah uses.

• Other possible explanations.

• How the belief affects eating and trust.

• A safe way of testing alternatives.

Cognitive restructuring

What is cognitive restructuring?

Cognitive restructuring is the process of identifying an unhelpful belief and developing a more balanced interpretation.

It involves:

1. Identifying the thought.

2. Examining the evidence.

3. Recognising its emotional and behavioural effects.

4. Considering alternative explanations.

5. Developing a less distressing interpretation.

AQA’s specimen mark scheme recognises cognitive restructuring, belief challenging and reality testing as central CBT techniques for schizophrenia.

Restructuring does not mean forced replacement

The therapist does not simply replace:

“The neighbours are monitoring me.”

with:

“The neighbours are definitely harmless.”

A more balanced conclusion might be:

“I feel watched, but there are several possible explanations and I do not currently have enough evidence to conclude that my neighbours are monitoring me.”

This interpretation:

• Recognises the person’s feeling.

• Reduces absolute certainty.

• Introduces alternatives.

• Avoids an unsupported opposite claim.

Reality testing

What is reality testing?

Reality testing involves checking whether a belief or interpretation is supported by observable evidence.

The therapist and client may ask:

• What evidence supports the belief?

• What evidence does not support it?

• Has the predicted event happened?

• Are there alternative explanations?

• Would another person interpret the event differently?

• How could the belief be tested safely?

Example

A person believes that every red car is following them.

The therapist might explore:

• How many red cars appear when the person is not travelling.

• Whether different red cars have different drivers.

• Whether the cars continue following after the person changes direction.

• The ordinary frequency of red cars.

• Whether attention to red cars has increased because of the belief.

The aim is not to ridicule the belief.

The aim is to examine the evidence systematically.

Reality testing and risk

Behavioural tests must be:

• Safe.

• Ethical.

• Agreed with the client.

• Proportionate.

• Unlikely to increase distress.

A therapist should not encourage a dangerous confrontation with someone believed to be threatening.

Socratic questioning

Socratic questioning involves asking carefully structured questions that help a person examine their own assumptions.

Possible questions include:

• What makes that explanation seem likely?

• Is there any evidence pointing in another direction?

• Has the prediction ever failed to happen?

• What might you say to a friend with the same concern?

• Are there less threatening explanations?

• How certain are you from 0 to 100?

• What would change your level of certainty?

The purpose is guided discovery rather than argument.

Why questions may be better than statements

A direct statement such as:

“Nobody is following you.”

may be rejected immediately.

A question such as:

“What evidence would we expect to find if someone were following you?”

encourages the person to take part in the reasoning process.

Challenging delusions

Delusions

A delusion is a strongly held belief that is not supported by available evidence and persists despite contradiction.

CBT may address delusions involving:

• Persecution.

• Grandeur.

• Control.

• Thought insertion.

• Personal messages.

Persecutory delusions

Suppose a person believes:

“My care workers are trying to harm me.”

The therapist may help the person identify:

• The events interpreted as threatening.

• Evidence that appears to support the belief.

• Evidence that care workers have provided help.

• Other explanations for their behaviour.

• The consequences of avoiding all care.

AQA’s November 2020 mark scheme suggested that a therapist could offer the alternative interpretation that the care workers were present to help and that providing support was their role.

Delusions of reference

Suppose a person believes:

“The newsreader sends me coded messages.”

The therapist might explore:

• Whether the same broadcast is shown to many viewers.

• Whether the person has met the presenter.

• Whether the supposed message is specific or ambiguous.

• How often the interpretation changes.

• Whether heightened attention is making ordinary comments feel personally relevant.

Delusions of control

Suppose a person believes:

“A machine controls my arm.”

The therapist may explore:

• What the person notices immediately before movement.

• Whether an intention or urge occurs.

• When the experience is stronger.

• Whether stress or attention affects it.

• Alternative explanations involving difficulty recognising self-generated action.

The cognitive explanation involving self-monitoring is covered in recognising thoughts and actions as self-generated [Cognitive explanations].

Challenging beliefs without confrontation

Why direct confrontation may fail

A person experiencing a delusion may regard contradiction as:

• Evidence that the therapist is involved.

• Proof that nobody understands.

• An attempt at control.

• A threat to their safety.

Effective CBT therefore tends to be:

• Gradual.

• Curious.

• Collaborative.

• Respectful.

• Focused on distress and functioning.

The AQA specimen mark scheme recognises that not every client is suited to forceful confrontation.

A graded approach

The therapist might begin by asking:

• How distressing is the belief?

• How much does it interfere with life?

• Is the person willing to explore it?

• Can uncertainty be introduced gradually?

A change from:

“I am 100% certain.”

to:

“I am 80% certain.”

may be clinically meaningful.

It creates room for alternative interpretations.

Working with hallucinations

The aim is not always to eliminate the voice

A person may continue to hear a voice after CBT.

Therapy may instead help them:

• Reinterpret its origin.

• Question its power.

• Reduce obedience.

• Feel less threatened.

• Use coping strategies.

• Continue daily activities.

AQA mark schemes recognise helping clients reinterpret voices as less threatening or as possible products of their own thoughts.

Examining the origin of the voice

The therapist might explore whether the voice could be:

• Inner speech.

• A memory.

• A self-generated thought.

• More likely during stress.

• Connected with particular emotions.

This links directly with source-monitoring explanations.

Examining the meaning of the voice

The client may believe:

• The voice is all-knowing.

• The voice can physically harm them.

• The voice must always be obeyed.

• The voice predicts the future.

• The voice reveals what everyone else thinks.

The therapist may examine evidence for each claim separately.

Examining the power of the voice

Questions might include:

• Has the voice ever made an incorrect prediction?

• What happens when you delay following an instruction?

• Has the voice carried out a threat?

• Does the voice become stronger during stress?

• Are there times when you can ignore it?

The aim is to weaken the belief that the voice has unlimited power.

Coping strategy enhancement

What is coping strategy enhancement?

Coping strategy enhancement involves identifying strategies that already help and improving their use.

The therapist and client may examine:

• What reduces distress.

• When symptoms become more severe.

• Which responses are helpful.

• Which responses increase the problem.

• How strategies can be used consistently.

AQA’s specimen mark scheme recognises coping strategy enhancement through education and targeting particular symptoms.

Possible coping strategies

Strategies may include:

• Positive self-talk.

• Self-distraction.

• Listening to music.

• Relaxation.

• Grounding activities.

• Social contact.

• Structured activity.

• Focusing attention elsewhere.

• Recording when symptoms occur.

• Reminding oneself that the voice has been wrong before.

The strategy should be selected according to the individual.

Positive self-talk

Positive self-talk involves using prepared statements to respond to distressing thoughts or voices.

For example:

• “This has happened before and it passed.”

• “I do not have to follow the voice.”

• “A thought is not the same as a fact.”

• “There may be another explanation.”

• “I can contact someone I trust.”

AQA explicitly identifies positive self-talk as a possible CBT strategy.

Self-distraction

A person may use an activity that redirects attention, such as:

• Speaking with someone.

• Listening to music.

• Completing a practical task.

• Walking in a familiar safe place.

• Focusing on an absorbing activity.

The November 2020 mark scheme accepted self-distraction and methods of reducing the perceived sound of voices as relevant strategies.

Relaxation

Relaxation may reduce physiological arousal associated with:

• Fear.

• Suspicion.

• Voices.

• Stressful social situations.

Possible techniques include:

• Controlled breathing.

• Progressive muscle relaxation.

• Guided calming exercises.

Relaxation does not directly prove that a belief is inaccurate.

It reduces the level of distress that may make careful reasoning difficult.

Behavioural components of CBT

CBT includes behavioural as well as cognitive techniques.

The person may be encouraged to:

• Increase social activity.

• Re-establish routines.

• Test predictions.

• Reduce avoidance.

• Complete manageable tasks.

• Practise coping strategies.

AQA’s June 2021 mark scheme identifies increased social activity and relaxation as possible CBT components.

Behavioural avoidance

Suppose a person believes that strangers intend to harm them.

They avoid:

• Shops.

• Public transport.

• Appointments.

• Friends.

Avoidance may maintain the belief because the person never gathers evidence that ordinary contact can be safe.

A graded behavioural task could involve:

1. Briefly entering a quiet shop with support.

2. Recording what was predicted.

3. Recording what actually happened.

4. Comparing the prediction with the outcome.

5. Increasing activity gradually.

Behavioural experiments

A behavioural experiment is an agreed activity designed to test a prediction.

For example:

Prediction:

“If I do not obey the voice immediately, something terrible will happen.”

Experiment:

Delay the response for a short, agreed and safe period.

Outcome:

Record whether the predicted event occurs.

The result provides evidence that can be used during cognitive restructuring.

The ABCDE framework

AQA’s specimen mark scheme accepts an ABCDE framework as one way to explain cognitive restructuring in CBT for schizophrenia.

A: Activating event

The event or experience that begins the sequence.

Example:

A stranger looks towards the person.

B: Belief

The person’s interpretation.

Example:

“The stranger is monitoring me.”

C: Consequences

The resulting emotions and behaviour.

Example:

• Fear.

• Leaving the area.

• Avoiding public places.

D: Disputation

The therapist and client examine the belief.

Questions include:

• What evidence supports it?

• What evidence contradicts it?

• Are there alternative explanations?

• Has the prediction been tested?

E: Effective or restructured belief

A more balanced interpretation is developed.

Example:

“The stranger may simply have looked in my direction. I cannot know that they were monitoring me.”

ABCDE worked example

Stage	Example
A	A care worker knocks at the door
B	“They have come to attack me”
C	Fear and locking every entrance
D	Examine previous visits and the care worker’s role
E	“I feel threatened, but previous visits have involved support rather than harm”

Psychoeducation

What is psychoeducation?

Psychoeducation involves helping the person understand:

• Schizophrenia symptoms.

• Possible triggers.

• Cognitive explanations.

• Treatment options.

• Coping strategies.

• Relapse warning signs.

Better understanding may help the person recognise that:

• Stress can affect symptoms.

• A voice does not have to be obeyed.

• A belief can be examined.

• Different explanations are possible.

• Help is available.

Education should not become a lecture in which the therapist assumes complete authority.

It should connect with the person’s own experience.

Homework and self-monitoring

CBT often involves work between sessions.

The person may record:

• When a voice occurs.

• What happened beforehand.

• What the voice said.

• How threatening it felt.

• What they believed it meant.

• Which coping strategy they used.

• Whether the strategy helped.

Thought diary

A thought diary might include:

Situation	Thought or belief	Emotion	Behaviour	Alternative interpretation
Neighbour closes curtains	“They are hiding surveillance equipment”	Fear	Avoid neighbour	“They may simply want privacy”

Benefits

Self-monitoring can help identify:

• Patterns.

• Triggers.

• Effective strategies.

• Changes over time.

• Links between beliefs and behaviour.

Limitations

Keeping detailed records may be difficult where the person experiences:

• Severe cognitive disorganisation.

• Speech or writing difficulties.

• Avolition.

• High distress.

• Suspicion about written information.

Homework should therefore be adapted to the individual.

CBT and negative symptoms

CBT is most clearly linked with:

• Delusions.

• Hallucinations.

• Distressing interpretations.

• Coping with intrusive thoughts.

It may also address negative symptoms through:

• Increasing activity.

• Establishing manageable goals.

• Rebuilding routines.

• Reducing avoidance.

• Encouraging social contact.

However, severe avolition may make it difficult to:

• Attend sessions.

• Complete homework.

• Practise strategies.

• Initiate behavioural tasks.

CBT may therefore be less accessible to some people experiencing severe negative symptoms.

CBT and medication

CBT may be delivered alongside dopamine-blocking medication or broader-acting drug treatments.

What medication may contribute

Medication may:

• Reduce the intensity of voices.

• Reduce delusional preoccupation.

• Lower severe agitation.

• Make sustained conversation easier.

What CBT may contribute

CBT may:

• Examine beliefs that remain.

• Reduce fear.

• Improve coping.

• Increase the person’s active involvement.

• Address meanings that medication does not change.

Combined pathway

medication reduces symptom intensity → person can engage in CBT → CBT changes interpretations and coping

The combined use of biological and psychological treatment is explored in biological vulnerability and psychological intervention.

CBT and family therapy

CBT works primarily with the individual’s:

• Thoughts.

• Interpretations.

• Emotions.

• Behaviour.

Improving communication and reducing expressed emotion works with:

• Relatives.

• Family communication.

• Criticism.

• Hostility.

• Emotional over-involvement.

CBT	Family therapy
Mainly individual treatment	Involves family members
Challenges beliefs and interpretations	Changes family interaction
Develops personal coping strategies	Develops shared communication strategies
May reduce distress from voices	May reduce stress and relapse
Requires individual engagement	Requires family participation

Both treatments may be used together.

Applying CBT to schizophrenia

Scenario 1: persecutory delusion

Imran believes that his support workers are planning to poison him. He refuses to eat food they prepare.

A cognitive behaviour therapist might:

• Identify Imran’s belief about poisoning.

• Explore what evidence he uses.

• Examine previous occasions when he ate safely.

• Consider other reasons the workers prepare food.

• Develop a safe behavioural test.

• Help Imran construct a less threatening interpretation.

• Reduce avoidance gradually.

Scenario 2: threatening voice

Chloe hears a voice telling her that she is worthless and must remain indoors.

The therapist might:

• Explore when the voice occurs.

• Examine whether stress increases it.

• Consider whether it could be internally generated.

• Question the voice’s authority and accuracy.

• Review occasions when Chloe ignored it without harm.

• Develop positive self-talk.

• Plan a graded increase in activity.

Scenario 3: thought insertion

Ravi believes that a machine sends thoughts into his mind.

The therapist might:

• Ask Ravi to describe when the thoughts appear.

• Explore whether similar thoughts arise during worry or stress.

• Examine evidence for the machine.

• Consider a source-monitoring explanation.

• Develop the alternative possibility that the thoughts are self-generated but feel unfamiliar.

• Practise responding to thoughts without treating them as commands.

Scenario 4: links between cognition and behaviour

Martine believes that care workers are trying to hurt her. She feels frightened and locks every door and window.

The AQA mark scheme credited:

• Identifying the persecutory belief.

• Exploring the possibility that voices are internally generated.

• Showing the link between belief, fear and locking behaviour.

• Offering an alternative interpretation that care workers are there to help.

• Teaching distraction or positive self-talk.

A complete application structure

Use:

scenario detail → belief or interpretation → CBT technique → likely benefit

For example:

“Ellis believes that the television presenter is warning him personally. The therapist could use reality testing by asking what evidence shows that the broadcast was directed specifically at him and whether other viewers received the same programme. Developing the alternative interpretation that the presenter was addressing a general audience may reduce Ellis’s fear.”

Evaluating CBT

Strength: it addresses the meaning of symptoms

Medication may reduce neural activity linked with a voice, but it does not necessarily address what the voice means to the person.

CBT can examine beliefs such as:

• “The voice is all-powerful.”

• “I must obey it.”

• “Hearing the voice means I am in immediate danger.”

• “The voice knows everything.”

Reducing these beliefs may lower distress even where the voice remains.

This gives CBT an important person-centred benefit.

Strength: it gives the person an active role

The client participates in:

• Identifying thoughts.

• Testing predictions.

• Developing alternatives.

• Selecting coping strategies.

• Monitoring progress.

This may increase:

• Autonomy.

• Confidence.

• Self-understanding.

• Sense of control.

In contrast, drug therapy can place the person in a more passive role where treatment is

administered to them.

Limitation: active participation is required

CBT requires a degree of:

• Insight.

• Communication.

• Concentration.

• Motivation.

• Willingness to examine beliefs.

AQA identifies self-awareness and willingness to engage as important suitability issues. Positive symptoms may reduce insight, while negative symptoms may reduce motivation or ability to take part.

A person experiencing severe psychosis may:

• Distrust the therapist.

• Be unable to concentrate.

• Refuse to discuss the belief.

• Find structured tasks overwhelming.

CBT may therefore be unsuitable until acute symptoms have reduced.

Strength: coping strategies may have lasting value

Medication produces its biological effect while it remains active in the body.

CBT teaches skills that the person may continue using after sessions end.

These include:

• Reality testing.

• Positive self-talk.

• Identifying triggers.

• Considering alternatives.

• Managing voices.

• Reducing avoidance.

This creates the possibility of longer-term self-management.

Limitation: skills may not generalise

A person may use a strategy effectively:

• In the therapy room.

• With one particular voice.

• During a period of low stress.

but struggle when:

• Symptoms become intense.

• The therapist is absent.

• A new delusion develops.

• A major life event occurs.

Follow-up evidence is needed to show that improvement continues across situations.

Strength: CBT avoids physical side effects

CBT does not directly produce drug side effects such as:

• Tremors.

• Muscle stiffness.

• Weight gain.

• Sedation.

• Blood-cell abnormalities.

This may make it more appropriate for people who:

• Respond poorly to medication.

• Cannot tolerate particular drugs.

• Prefer psychological intervention.

Counterpoint

CBT is not free from costs.

It may involve:

• Emotional discomfort.

• Anxiety while examining beliefs.

• Frustration.

• Time commitment.

• Distress during behavioural experiments.

“Psychological” does not mean completely risk-free.

Limitation: CBT can be distressing

Discussing:

• Threatening voices.

• Persecutory beliefs.

• Traumatic experiences.

• Previous crises.

may temporarily increase distress.

Reality testing may also feel threatening if the person experiences the therapist as:

• Disbelieving them.

• Taking away a source of meaning.

• Attempting to control their thoughts.

The therapist must proceed gradually and maintain informed consent.

Strength: CBT may improve more than symptom scores

Possible benefits include:

• Reduced distress.

• Greater social activity.

• Better coping.

• Improved confidence.

• Better understanding of triggers.

• Increased willingness to seek help.

• Improved adherence to an agreed treatment plan.

AQA’s June 2021 mark scheme recognises broader evaluation in terms of medication compliance, practicalities and suitability for different patient groups.

Limitation: improvement can be difficult to measure

Success might mean:

• Fewer voices.

• Less belief conviction.

• Reduced fear.

• Better functioning.

• Fewer hospital admissions.

• Improved quality of life.

A person may improve on one measure but not another.

For example:

The voice remains frequent, but the person is no longer frightened by it.

A symptom-frequency measure might show little improvement, while quality of life has improved considerably.

Limitation: CBT may manage rather than remove symptoms

CBT often changes the person’s relationship with the symptom.

It may not eliminate:

• Hallucinations.

• Biological vulnerability.

• Dopamine dysfunction.

• Structural brain differences.

Critics may argue that it manages the psychological consequences rather than treating the original cause.

This criticism should be balanced carefully.

Reducing distress and improving functioning are meaningful outcomes even when an underlying vulnerability remains.

Limitation: it may not address biological causes

Schizophrenia has strong biological explanations involving:

• Genetic vulnerability.

• Neural correlates.

• Dopamine activity.

CBT does not directly alter these processes in the way medication targets neurotransmitter functioning.

A person with severe biological vulnerability may therefore require antipsychotic treatment as well.

This supports a combined rather than exclusively cognitive approach.

Strength: the treatment follows from cognitive explanations

CBT has theoretical coherence.

If distress is partly maintained by:

• Maladaptive beliefs.

• Source-monitoring errors.

• Threatening interpretations.

• Avoidance.

then changing these processes should improve outcomes.

The treatment therefore follows logically from cognitive accounts of symptom formation [Cognitive explanations].

Treatment effectiveness does not prove the explanation

Even where CBT helps, this does not prove that dysfunctional cognition was the original cause of schizophrenia.

A treatment may reduce distress without identifying why the symptom first appeared.

For example:

• Dopamine dysfunction may contribute to an unusual experience.

• CBT may help the person interpret that experience less threateningly.

Both explanations can be correct at different levels.

Limitation: lengthy treatment

CBT generally requires repeated sessions.

This creates practical difficulties involving:

• Therapist time.

• Cost.

• Travel.

• Appointment attendance.

• Availability of trained practitioners.

• Maintaining engagement.

The AQA specimen mark scheme identifies the length of therapy and dropout during severe episodes as relevant limitations.

Comparison with medication

Medication may be:

• Administered quickly.

• Used during acute psychosis.

• Less dependent on verbal discussion.

CBT may take longer to produce benefits but can provide personalised coping skills.

The treatment choice depends on the person’s needs and current condition.

Limitation: access to skilled therapists

Effective CBT for schizophrenia requires a practitioner who can:

• Understand psychosis.

• Build trust.

• Avoid aggressive confrontation.

• Adapt techniques to cognitive difficulties.

• Manage risk.

• Integrate treatment with wider care.

AQA recognises the availability of skilled practitioners and an appropriate setting as relevant practical issues.

Where trained therapists are unavailable:

• Waiting lists may be long.

• Treatment may begin late.

• Sessions may be too limited.

• Quality may vary.

Limitation: dropout and selection effects

People who complete CBT may differ from those who leave.

Completers may be:

• More motivated.

• Less severely unwell.

• More articulate.

• More trusting of services.

• Better supported.

Research including only completers may therefore exaggerate effectiveness.

The people most likely to struggle with CBT may disappear from the final results.

Limitation: therapist effects

CBT depends heavily on the therapist.

Outcomes may vary according to:

• Skill.

• Experience.

• Warmth.

• Ability to form a therapeutic alliance.

• Adherence to the treatment plan.

• Cultural understanding.

A positive outcome may partly reflect supportive contact rather than the specific cognitive techniques.

Researchers need suitable comparison conditions to separate:

• CBT techniques.

• General therapist attention.

• Expectation of improvement.

Limitation: difficulties with blind procedures

In a drug trial, a participant may not know whether they receive an active drug or placebo.

In a CBT trial:

• The client knows they are receiving therapy.

• The therapist knows they are delivering it.

A fully double-blind procedure is therefore impossible.

This increases the possibility of:

• Expectancy effects.

• Demand characteristics.

• Therapist enthusiasm influencing outcomes.

Independent assessors can be kept unaware of treatment allocation, which reduces some bias.

Researching CBT effectiveness

Randomised controlled trial

Participants may be allocated to:

• CBT plus usual care.

• Usual care alone.

• Another psychological treatment.

• Supportive counselling.

Random allocation reduces systematic participant differences.

Baseline measurement

Researchers should measure symptoms before therapy begins.

Without a baseline, they cannot determine how much each participant changed.

Outcome measurement

Possible outcomes include:

• Hallucination severity.

• Delusional conviction.

• Distress.

• Social functioning.

• Quality of life.

• Relapse.

• Hospital admission.

Follow-up

Assessment should continue after therapy ends.

Immediate improvement may not demonstrate lasting effectiveness.

Attrition

Researchers should record:

• How many participants began treatment.

• How many completed it.

• Why participants left.

• Whether withdrawal differed between groups.

CBT and the medical model

CBT does not rely entirely on the medical model.

It treats the client as someone capable of:

• Understanding experiences.

• Developing skills.

• Making choices.

• Testing interpretations.

• Taking an active role.

This may reduce biological determinism and fatalism.

However, CBT is often delivered within medical services and alongside medication.

It is therefore not wholly separate from biological treatment.

Cognitive reductionism

CBT may be criticised for focusing too narrowly on thoughts and beliefs.

Schizophrenia may also involve:

• Genes.

• Dopamine.

• Brain development.

• Family stress.

• Social disadvantage.

• Trauma.

• Discrimination.

• Housing difficulties.

Changing thoughts alone may be insufficient where the person’s environment remains threatening or unstable.

Counterargument

CBT can be relatively holistic when it considers:

• Emotions.

• Behaviour.

• Relationships.

• Social activity.

• Stress.

• Medication.

• The person’s individual history.

AQA’s 2021 mark scheme identifies holism versus reductionism as a relevant broader issue when evaluating CBT.

Ethical advantages

CBT can increase autonomy because it:

• Involves the person in decisions.

• Provides information.

• Develops personal strategies.

• Does not depend solely on medication.

• Can be adapted to individual goals.

The client is not merely instructed to comply.

Ethical concerns

CBT can become unethical if a therapist:

• Ridicules a belief.

• Forces confrontation.

• Ignores cultural context.

• Treats disagreement as lack of insight.

• Pressures the person to accept the therapist’s explanation.

• Uses risky behavioural experiments.

The person should remain involved in deciding:

• Which beliefs to examine.

• Which goals matter.

• Which experiments are acceptable.

• Whether to continue.

Cultural considerations

Beliefs must be interpreted within cultural context.

A therapist should not automatically challenge:

• Religious beliefs.

• Spiritual experiences.

• Culturally shared interpretations.

The relevant questions include:

• Is the belief shared within the person’s culture?

• Is it causing distress?

• Does it lead to harmful behaviour?

• How does the client understand it?

• Is the therapist imposing their own cultural assumptions?

This links with culture bias in the diagnosis of schizophrenia.

CBT and personal responsibility

An emphasis on changing thoughts may be misinterpreted as suggesting:

“The person is responsible for having schizophrenia because they think incorrectly.”

This would be inappropriate.

Dysfunctional cognitive processing may be:

• Automatic.

• Influenced by biology.

• Influenced by stress.

• Outside voluntary control.

CBT gives the person opportunities to respond differently. It does not mean they caused the original condition.

Effectiveness versus appropriateness

Effectiveness

Does CBT produce useful outcomes?

Possible indicators include:

• Reduced symptom severity.

• Lower distress.

• Better coping.

• Improved social functioning.

• Reduced relapse.

• Better quality of life.

Appropriateness

Is CBT suitable for this particular person?

Consider:

• Insight.

• Motivation.

• Communication ability.

• Symptom severity.

• Cognitive functioning.

• Therapist availability.

• Cultural context.

• The person’s preferences.

A treatment may be effective on average but inappropriate during a severe acute episode.

When CBT may be particularly appropriate

CBT may be useful when the person:

• Continues to experience symptoms despite medication.

• Wants non-drug support.

• Experiences distressing interpretations.

• Has enough stability to engage.

• Wants practical coping strategies.

• Experiences medication side effects.

• Wishes to understand triggers and relapse signs.

When CBT may be less appropriate

CBT may be difficult when the person:

• Is extremely distressed.

• Cannot sustain attention.

• Has severe speech poverty.

• Experiences intense avolition.

• Does not trust the therapist.

• Does not accept that thoughts can be examined.

• Is unable or unwilling to attend regularly.

This does not mean CBT should never be offered.

Treatment may need to be:

• Delayed.

• Adapted.

• Shortened.

• Combined with medication.

• Delivered more flexibly.

Overall assessment of CBT

Main strengths

• Directly addresses beliefs and interpretations.

• Can reduce distress even when symptoms continue.

• Gives the person an active role.

• Develops transferable coping strategies.

• Does not produce physical drug side effects.

• Can improve social activity and functioning.

• Can be combined with medication and family therapy.

• Provides individualised treatment.

Main limitations

• Requires motivation, insight and communication.

• May be difficult during severe episodes.

• Requires skilled therapists and repeated sessions.

• Can be emotionally demanding.

• May have high dropout among some groups.

• Does not directly remove biological vulnerability.

• Benefits may vary between people.

• Research cannot be fully double blind.

• Therapy may manage symptoms rather than cure schizophrenia.

A balanced conclusion

CBT is most convincing when judged by more than whether hallucinations or delusions disappear completely.

A person may benefit because they:

• Feel safer.

• No longer obey a threatening voice.

• Question a persecutory interpretation.

• Resume social activities.

• Recognise triggers.

• Develop greater control.

CBT is therefore an important psychological treatment, but it is unlikely to meet every need when used alone.

The strongest approach often combines:

medication to reduce symptom intensity + CBT to address beliefs and coping + social or family support to reduce environmental stress

Hints from the Examiner Reports 💡

Examiner hint: Keep CBT linked specifically to schizophrenia.

A generic description of changing negative thoughts is not enough. Refer to:

• Hallucinations.

• Delusions.

• Intrusive thoughts.

• The origin of voices.

• Distress.

• Coping strategies.

The specimen mark scheme states that an answer should contain a clear link to schizophrenia rather than a generic CBT outline.

Examiner hint: Explain how beliefs are challenged.

Do not write only:

“The therapist challenges the delusion.”

Explain that the therapist:

1. Identifies the belief.

2. Examines evidence.

3. Considers alternatives.

4. Tests predictions where safe.

5. Develops a less distressing interpretation.

Examiner hint: Apply each technique to the actual symptom.

The November 2020 question required students to explain treatment of a woman who believed that care workers intended harm and heard voices telling her to lock doors. Credit was available for linking her belief with fear and behaviour and offering specific alternative interpretations and coping strategies.

Examiner hint: Do not portray CBT as aggressive confrontation.

A therapist should not simply tell the person:

“The voices are fake.”

A stronger answer explains collaborative reality testing and exploration of whether the voices could originate from the person’s own thoughts.

Examiner hint: Mention coping as well as belief challenging.

AQA accepts:

• Positive self-talk.

• Self-distraction.

• Relaxation.

• Increased social activity.

• Strategies for managing intrusive thoughts.

Examiner hint: Evaluation should be relevant to people with schizophrenia.

A generic statement that therapy “takes a long time” is weaker than:

“Repeated sessions require sustained motivation and concentration, which may be difficult for a person experiencing avolition or severe cognitive disorganisation.”

Examiner hint: Distinguish symptom reduction from distress reduction.

CBT may be effective even where a voice remains, provided the person:

• Feels less frightened.

• Believes it has less power.

• No longer obeys it.

• Functions more successfully.

Examiner hint: Evaluate suitability.

The June 2021 mark scheme identifies:

• Need for insight.

• Suitability for different patient groups.

• Availability of skilled therapists.

• Practical difficulties.

• Comparison with alternative treatments.

Examiner hint: Use the stem throughout an application essay.

Do not describe CBT for several paragraphs and then add one sentence repeating the scenario.

Link each detail directly with:

• A belief.

• An emotion.

• A behaviour.

• A CBT technique.

• An intended outcome.

Common Mistakes ⚠️

Mistake: Saying CBT removes dopamine

Why this is incorrect:

CBT is a psychological treatment.

How to improve:

Use antipsychotics for neurotransmitter action and CBT for beliefs, interpretations and coping.

Mistake: Saying CBT cures schizophrenia

Why this is too strong:

Symptoms or biological vulnerability may remain.

How to improve:

Refer to reduced distress, improved coping and better functioning.

Mistake: Saying the therapist tells the client that everything is imaginary

Why this is inaccurate and confrontational:

The person genuinely experiences the symptom.

How to improve:

Explain collaborative exploration of origin and meaning.

Mistake: Treating a hallucination as a belief

Why this is incorrect:

A hallucination is a sensory experience. A delusion is a belief.

How to improve:

Explore the meaning of a hallucination and the evidence for a delusion.

Mistake: Writing only “challenge irrational thoughts”

Why this is too vague:

It does not explain the therapeutic process.

How to improve:

Include evidence, alternatives, reality testing or behavioural experiments.

Mistake: Challenging the person instead of the interpretation

Why this is inappropriate:

CBT should not frame the person as the problem.

How to improve:

Examine the belief collaboratively.

Mistake: Saying CBT proves voices are not real

Why this is too simplistic:

The experience is real to the person, while its source may be interpreted differently.

How to improve:

Explore whether the voice could be internally generated and whether it has the power attributed to it.

Mistake: Assuming every belief should be challenged

Why this is incorrect:

Some beliefs may be culturally shared or unrelated to distress.

How to improve:

Focus on interpretations causing distress, risk or impaired functioning.

Mistake: Forgetting behaviour

Why this is incomplete:

CBT is cognitive and behavioural.

How to improve:

Discuss activity, avoidance, coping practice and behavioural testing.

Mistake: Giving an unsafe behavioural experiment

Why this is inappropriate:

Tests must not expose the client to serious risk.

How to improve:

Describe a gradual, collaborative and safe test.

Mistake: Describing CBT for depression

Why this loses focus:

Schizophrenia CBT focuses particularly on voices, delusions and intrusive experiences.

How to improve:

Use schizophrenia-specific applications.

Mistake: Saying the client must admit that they are wrong

Why this is inaccurate:

The goal is increased flexibility rather than forced agreement.

How to improve:

Refer to considering alternatives and reducing certainty.

Mistake: Treating positive self-talk as positive thinking generally

Why this is vague:

A coping statement should address the specific symptom.

How to improve:

Give an example such as, “I do not have to obey this voice.”

Mistake: Saying CBT has no side effects, so it has no disadvantages

Why this is incorrect:

It may be distressing, time-consuming and difficult to access.

How to improve:

Distinguish physical drug side effects from psychological and practical costs.

Mistake: Saying CBT is appropriate for everyone

Why this is inaccurate:

Severe positive or negative symptoms may prevent engagement.

How to improve:

Evaluate insight, motivation, communication and symptom severity.

Mistake: Claiming CBT effectiveness proves schizophrenia has a cognitive cause

Why this is incorrect:

A treatment can help symptoms without identifying their original cause.

How to improve:

Present cognitive and biological explanations as potentially compatible.

Mistake: Listing limitations without explaining consequences

Why this is incomplete:

“CBT takes time” is a statement rather than developed evaluation.

How to improve:

Explain how repeated sessions may increase cost, waiting time and dropout.

Exam-Style Questions ✍️

Questions

1. What is meant by cognitive behaviour therapy?[2 marks]

2. Explain what psychologists mean by cognitive restructuring.[3 marks]

3. Explain how reality testing may be used in CBT for schizophrenia.[4 marks]

4. Explain one way in which CBT might help a person who hears threatening voices.[4 marks]

5. Ella believes that her care workers intend to harm her. She feels frightened and refuses to open her door.

Explain how a cognitive behaviour therapist might treat Ella.[6 marks]

6. Explain how positive self-talk may be used as a coping strategy for schizophrenia.[3 marks]

7. Explain one cognitive and one behavioural component of CBT for schizophrenia.[4 marks]

8. Researchers compare CBT plus usual care with usual care alone. After treatment, the following numbers show participants reporting a meaningful reduction in distress:

Condition	Participants improving	Participants beginning treatment
CBT plus usual care	36	60
Usual care alone	24	60

a) Calculate the percentage improving in the CBT condition.[2 marks]

b) Calculate the percentage improving in the usual-care condition.[2 marks]

c) Explain one conclusion and one limitation of these findings.[4 marks]

9. Explain one reason why CBT may be unsuitable for some people with schizophrenia.[4 marks]

10. Explain one strength and one limitation of CBT as a treatment for schizophrenia.[6 marks]

11. Compare CBT and antipsychotic medication as treatments for schizophrenia.[8 marks]

12. Briefly outline how CBT is used to treat schizophrenia and explain one limitation of CBT.[4 marks]

13. Discuss CBT as a treatment for schizophrenia. Refer to the following scenario in your answer.

Nathan hears a voice telling him that he is in danger. He believes the voice has complete control over him and remains indoors whenever it speaks. Nathan’s medication has made the voice quieter, but he remains frightened and avoids friends and appointments.

[16 marks]

Answers and Mark Scheme

Question 1

Award up to two marks:

• CBT is a psychological treatment examining connections between thoughts or interpretations, emotions and behaviour.

• It aims to identify unhelpful beliefs and develop alternative interpretations or coping strategies.

Question 2

Award up to three marks:

• Cognitive restructuring involves identifying an unhelpful or distressing belief.

• The person examines evidence supporting and contradicting it.

• Alternative, more balanced interpretations are developed.

• The new interpretation should reduce distress or unhelpful behaviour.

Question 3

Award up to four marks:

• The therapist identifies a delusional or distressing belief.

• The client and therapist examine observable evidence for and against it.

• They consider alternative explanations.

• A prediction may be tested through a safe behavioural experiment.

• The person may develop a less threatening interpretation.

Question 4

Award up to four marks for one developed technique.

Possible answer:

• The therapist may explore whether the voice could originate from the person’s inner speech.

• They may question the belief that the voice is all-powerful.

• The client could examine occasions when the voice’s predictions were wrong.

• Positive self-talk or distraction may help manage it.

• This may reduce fear even if the voice remains.

Question 5

Award up to six marks:

• Ella’s belief that care workers intend harm is a persecutory belief.

• The therapist could identify the connection between this belief, her fear and refusal to open the door.

• Ella could examine evidence that appears to support the belief.

• She could also consider evidence that the care workers have provided support.

• The therapist could offer alternative interpretations of their visits.

• A safe behavioural test might involve brief planned contact with a trusted worker.

• A less threatening interpretation may reduce fear and avoidance.

Question 6

Award up to three marks:

• Positive self-talk uses prepared statements to respond to distressing thoughts or voices.

• For example, the person might remind themselves, “The voice has been wrong before, and I do not have to obey it.”

• This may reduce fear, increase control and support an alternative behaviour.

Question 7

Award up to two marks for each component.

Cognitive component:

• Identifying a delusional belief.

• Examining evidence.

• Developing an alternative interpretation.

Behavioural component:

• Testing a prediction safely.

• Increasing social activity.

• Reducing avoidance.

• Practising a coping strategy.

Question 8a

6036​×100=60%

Award:

• One mark for suitable working.

• One mark for 60%.

Question 8b

6024​×100=40%

Award:

• One mark for suitable working.

• One mark for 40%.

Question 8c

Award up to four marks.

Possible conclusion:

• A greater percentage improved with CBT plus usual care.

• The difference was 20 percentage points.

• The results are consistent with CBT providing an additional benefit.

Possible limitation:

• No inferential-test result is given, so statistical significance cannot be claimed.

• The groups may differ in dropout or initial symptom severity.

• The outcome measures distress rather than symptom frequency or long-term relapse.

• Participants know whether they receive CBT, creating expectation effects.

• The results do not show whether improvement continued at follow-up.

Question 9

Award up to four marks for one developed reason.

Possible answer:

• CBT requires active engagement, insight and sustained attention.

• Severe delusions may cause the person to distrust the therapist.

• Avolition may make attendance or homework difficult.

• The client may therefore withdraw or gain little benefit, reducing appropriateness and effectiveness.

Alternative answers include:

• Severe cognitive disorganisation.

• Speech poverty.

• Long waiting lists.

• Lack of skilled therapists.

• Distress caused by belief challenging.

Question 10

Award up to three marks for a developed strength and three marks for a developed limitation.

Possible strength:

CBT gives the person practical strategies for examining beliefs and managing voices. These strategies may reduce distress and increase autonomy even when hallucinations do not disappear completely.

Possible limitation:

CBT requires motivation and insight. A person experiencing severe avolition or persecutory delusions may struggle to attend, trust the therapist or complete tasks, so the treatment is not equally appropriate for everyone.

Alternative creditworthy points include:

• No physical drug side effects.

• Individualised treatment.

• Possible long-term coping skills.

• Length and cost.

• Therapist availability.

• Dropout.

• Difficulty conducting blind research.

• Failure to address biological vulnerability.

Question 11

A strong comparison may include:

• CBT is a psychological treatment, whereas antipsychotics are biological treatments.

• CBT addresses beliefs, meanings and coping.

• Medication alters neurotransmitter activity.

• CBT requires active participation.

• Medication may be administered more quickly during an acute episode.

• CBT does not produce movement or metabolic drug effects.

• CBT may still be time-consuming and emotionally demanding.

• Antipsychotics may reduce the intensity of positive symptoms.

• CBT may reduce distress even where symptoms remain.

• Both can improve functioning.

• Neither guarantees a cure.

• Both can have adherence difficulties.

• CBT may develop lasting skills.

• Medication’s effect depends partly on continued biological action.

• The treatments may work best together.

Higher marks require direct comparison rather than two separate descriptions.

Question 12

Award up to two marks for the outline and two marks for the limitation.

Possible outline:

• CBT identifies and challenges beliefs, including interpretations of voices.

• Reality testing and alternative interpretations may reduce distress.

• Positive self-talk or coping strategies may also be developed.

Possible limitation:

• CBT requires self-awareness and willingness to engage.

• Severe positive symptoms may reduce insight, while negative symptoms may reduce motivation.

• Some people may therefore struggle to take part or complete therapy.

This structure reflects the AQA specimen mark allocation of AO1 and AO3.

Question 13

A strong response should include:

Knowledge and understanding

• CBT as a psychological treatment.

• Connections between thoughts, emotions and behaviour.

• Collaborative therapist-client relationship.

• Cognitive formulation.

• Identifying delusional or intrusive beliefs.

• Cognitive restructuring.

• Reality testing.

• Examining evidence.

• Developing alternative interpretations.

• Exploring the origin and meaning of voices.

• Questioning the power attributed to voices.

• Positive self-talk.

• Self-distraction.

• Relaxation.

• Behavioural experiments.

• Increasing social activity.

• Reducing avoidance.

• Homework and self-monitoring.

Application

• Nathan’s voice is an auditory hallucination.

• He believes the voice has complete control, which increases fear.

• Remaining indoors is an avoidance behaviour.

• The therapist could explore whether the voice’s predictions have always been accurate.

• Nathan could examine occasions when he did not obey and no harm occurred.

• The therapist could question whether the voice truly possesses complete power.

• Nathan might develop the alternative interpretation that the voice is distressing but cannot control every action.

• Positive self-talk could include, “I can choose not to follow the voice.”

• A graded behavioural task could involve brief contact with a trusted friend.

• Medication has reduced the voice’s intensity but has not changed Nathan’s interpretation.

• CBT could therefore complement medication.

Evaluation

• CBT addresses the meaning of symptoms rather than only their frequency.

• It may reduce distress even when voices remain.

• It gives the client an active role.

• Coping skills may continue beyond therapy.

• It avoids physical drug side effects.

• It may improve social activity and quality of life.

• Nathan’s fear may make engagement difficult.

• Severe symptoms can reduce insight and trust.

• Avolition or cognitive disorganisation may limit participation.

• Therapy requires repeated sessions and skilled practitioners.

• Dropout can reduce effectiveness.

• Outcomes may depend on the therapeutic alliance.

• Fully double-blind research is impossible.

• CBT may manage symptoms without changing biological vulnerability.

• Medication may be needed before meaningful engagement becomes possible.

• Combined treatment addresses biological and cognitive processes.

• CBT should be collaborative rather than confrontational.

• Appropriateness depends on Nathan’s preferences, insight and readiness.

Higher-level answers will explain the treatment process in detail, apply each separate part of the scenario and distinguish reducing the voice itself from reducing Nathan’s threatening interpretation and avoidance.