An-Najah National University Faculty of Graduate Studies THE EFFECT OF COGNITIVE BEHAVIORAL THERAPY IN TREATING HALLUCINATIONS AND DELUSIONS AMONG PATIENTS WITH SCHIZOPHRENIA: A QUASI-EXPERIMENTAL TRIAL By Salsabeel Sameh Hashem Zamareh Supervisor Dr. Adnan Sarhan This Thesis is Submitted in Partial Fulfillment of the Requirements for the Degree of Master of Community Mental Health Nursing, Faculty of Graduate Studies, An-Najah National University, Nablus - Palestine. 2024 II THE EFFECT OF COGNITIVE BEHAVIORAL THERAPY IN TREATING HALLUCINATIONS AND DELUSIONS AMONG PATIENTS WITH SCHIZOPHRENIA: A QUASI-EXPERIMENTAL TRIAL By Salsabeel Sameh Hashem Zamareh This Thesis was Defended Successfully on 72/4/2024 and approved by Dr. Adnan Sarhan Supervisor Signature Dr. Salam Alkhatib External Examiner Signature Dr. Shadi Abualkibash Internal Examiner Signature III Dedication I dedicate this research to: The sake of Allah, my creator and master, my mother and husband. The two persons that gave the tools and values necessary to be where I am standing today, who have been my constant source of love and support and I am grateful for the sacrifices they have made to help me pursue my dreams. And to the soul of my late father. I would also like to express my gratitude to my professors, especially to my supervisor Dr. Adnan Sarhan whose guidance and expertise have challenged me to grow and develop as a student. Their dedication to teaching and commitment to excellence have been a source of motivation and inspiration and I am honored to have had the opportunity to learn from them. Finally, I would like to acknowledge my family, classmates and friends, whose support have made this journey more fulfilling. Their encouragement, collaboration have helped me to overcome obstacles and celebrate achievements. May Allah accept this work. IV Acknowledgements Words cannot express my gratitude to my supervisor Dr. Adnan Sarhan for his invaluable patience and feedback. I could not have undertaken this journey without my professors, who generously provided knowledge and expertise. Additionally, this endeavor would not have been possible without the generous support of my family and dear husband, who stood by my side during my educational journey. Their belief in me has kept my spirits and motivation high during this process. Lastly, I am also grateful to my classmates and for everyone who has stood by my side and helped me in carrying out my research. V Declaration I, the undersigned, declare that I submitted the thesis entitled: THE EFFECT OF COGNITIVE BEHAVIORAL THERAPY IN TREATING HALLUCINATIONS AND DELUSIONS AMONG PATIENTS WITH SCHIZOPHRENIA: A QUASI-EXPERIMENTAL TRIAL I declare that the work provided in this thesis, unless otherwise referenced, is the researcher‘s own work, and has not been submitted elsewhere for any other degree or qualification. _____________________________________ Student's Name: _____________________________________ Signature: _____________________________________ Date: VI List of Contents Dedication ........................................................................................................................ II Acknowledgements ......................................................................................................... IV Declaration ....................................................................................................................... V List of Contents ............................................................................................................... VI List of Tables ............................................................................................................... VIII List of Figures ................................................................................................................. IX List of Appendices ........................................................................................................... X Abstract ........................................................................................................................... XI Chapter One: Introduction ................................................................................................ 1 1.1 Theoretical Models of Psychosis and CBTp ............................................................... 5 1.1.1 The ABC cognition model ....................................................................................... 5 1.2 Problem statement ....................................................................................................... 6 1.3 Significance of the Study ............................................................................................ 8 1.4 Research Objectives .................................................................................................... 8 1.5 Research Questions ..................................................................................................... 9 1.6 Research Hypothesis ................................................................................................... 9 Chapter Two: Methodology ............................................................................................ 13 2.1 Study Design and Sampling Technique .................................................................... 13 2.2 Inclusion and exclusion criteria ................................................................................ 13 2.3 Study Setting ............................................................................................................. 13 2.4 Study Instrument ....................................................................................................... 14 2.4.1 The Psychotic Symptom Rating Scales (PSYRATS) ............................................ 14 2.4.2 Positive and Negative Syndrome Scale (PANSS) ................................................. 15 2.5 Procedure .................................................................................................................. 16 7.5.1 Engagement ........................................................................................................... 19 7.5.2 Assessing Psychotic Experiences .......................................................................... 20 7.5.3 Recognizing Problems ........................................................................................... 20 2.5.4 Interventions .......................................................................................................... 22 7.6 Ethical considerations ............................................................................................... 28 7.7 Data Analysis ........................................................................................................... 28 Chapter Three: Results .................................................................................................... 30 3.1 Introduction ............................................................................................................... 30 3.2 Demographic Characteristics of the participants ...................................................... 30 VII 3.3 Effectiveness of CBT treatment on auditory hallucination and on the intensity and amount of distress in auditory hallucinations domain among participants .............. 32 3.4 The effectiveness of CBT treatment on delusions and the amount and intensity of distress in delusion domain among participants ...................................................... 34 3.5 Effectiveness of CBT treatment on schizophrenia severity and anxiety in the Schizophrenia Severity domain Among Participants .............................................. 36 3.6 Factors that Affect Participants' Outcome on Auditory Hallucinations, Delusions and Schizophrenia Severity (Post-test Sum Scores) ................................................ 38 Chapter Four: Discussions and Conclusions .................................................................. 40 4.1 Discussion ................................................................................................................. 40 4.2 Limitations ................................................................................................................ 45 4.3 Conclusion ................................................................................................................ 46 4.4 Recommendations ..................................................................................................... 47 List of Abbreviations ...................................................................................................... 48 Appendices ...................................................................................................................... 59 ب .............................................................................................................................. الملخص VIII List of Tables Table 1: Socio-demographic characteristics of the participants (n=20) ......................... 31 Table 2: The Effectiveness of CBT treatment on Auditory hallucinations and on the intensity and amount of distress in auditory hallucinations domain among participants (n=20) ............................................................................................ 33 Table 3: The effectiveness of CBT treatment on delusions and the amount and intensity of distress in the delusion domain among participants (n=20) ......................... 35 Table 4: The Effectiveness of CBT treatment on Schizophrenia Severity, and on the anxiety related to schizophrenia severity among participants (n=20) .............. 37 IX List of Figures Figure 1: The Effectiveness of CBT treatment on Auditory hallucinations among participants (n=20) ......................................................................................... 34 Figure 2: The Effectiveness of CBT treatment on delusion among participants (n=20) 36 Figure 3: The Effectiveness of CBT treatment on schizophrenia severity among participants (n=20) ......................................................................................... 38 X List of Appendices Appendix A: Task Facilitation ........................................................................................ 59 Appendix B: IRB approval letter .................................................................................... 60 Appendix C: Approval request to participate in a scientific research ............................ 61 Appendix D: The Psychotic Symptom Rating Scales (PSYRATS) ............................... 66 Appendix E: The Positive and Negative Syndrome Scale (PANSS) .............................. 72 Appendix F: Recommended Element of CBT for Psychosis ......................................... 95 XI THE EFFECT OF COGNITIVE BEHAVIORAL THERAPY IN TREATING HALLUCINATIONS AND DELUSIONS AMONG PATIENTS WITH SCHIZOPHRENIA: A QUASI-EXPERIMENTAL TRIAL By Salsabeel Sameh Hashem Zamareh Supervisor Dr. Adnan Sarhan Abstract Background: Schizophrenia is a leading cause of disability across the globe, affecting nearly 1% of the worldwide population. Cognitive Behavioral Therapy for Psychosis (CBTp) is recognized as an established therapeutic approach, proving effective in mitigating symptoms and enhancing the quality of life for those with psychotic disorders. CBTp is aimed at enhancing functionality while navigating through challenging symptoms such as hallucinations, negative symptoms, cognitive disturbances, and delusions. Method: This study employed a quasi-experimental methodology and was conducted at the Hebron mental health clinic from January to March 2023. It utilized two assessment tools: The Psychotic Symptom Rating Scales (PSYRATS) and the Positive and Negative Syndrome Scale (PANSS), with the SPSS version 28 for statistical analysis. Results: The intervention group showed a statistically significant improvement in post- test scores for auditory hallucinations, delusions, and overall severity of schizophrenia compared to the control group (p < 0.05). Furthermore, a significant reduction in distress and anxiety levels was noted in the intervention group's post-test scores compared to the control group (p < 0.05). Additionally, no significant differences were found in the outcomes related to auditory hallucinations, delusions, and schizophrenia severity across various demographic groups of participants (p > 0.05). Conclusion: The outcomes of this study highlight the pivotal contribution of CBT to the considerable decrease in overall psychotic symptoms, especially in positive symptoms, auditory hallucinations, and delusions within the case group. This work contributes to the growing evidence supporting the adaptation of validated interventions and the efficacy and acceptance of CBT in the treatment of psychosis. XII Keywords: Delusions, Hallucinations, Psychosis, Cognitive Behavioral Therapy (CBT). 1 Chapter One Introduction The understanding of psychosis has evolved through the historical context of mental disorder concepts for nearly 170 years. While "psychosis" has yet to be defined uniformly, it represents a clinical construct encompassing a variety of symptoms. At its core, psychosis is characterized by delusions, hallucinations, and disordered thinking. Investigations into what underlies psychotic symptoms suggest that they may stem from a mix of neuropsychological processes that lead to a distortion of reality (Gaebel & Zielasek, 2015). In the early version of the Diagnostic and Statistical Manual of Mental Disorders by the American Psychiatric Association (APA), psychosis was characterized as a significant disruption in reality testing or the erosion of ego boundaries, hindering an individual's ability to manage everyday life demands (Blashfield, 1973). However, the contemporary understanding of psychosis, as outlined by both the APA and the World Health Organization, adopts a more specific criterion. It mandates the occurrence of hallucinations (with a lack of awareness of their pathological origins), delusions, or a combination of both hallucinations without insight and delusions for a diagnosis (Sarmiento & Lau, 2020). Acute psychosis is categorized as primary when it manifests as a symptom of a psychiatric condition, or secondary when it arises from a specific medical issue. Individuals experiencing primary acute psychosis typically present with auditory hallucinations, significant disturbances in cognition, and complex delusions. In contrast, psychosis stemming from a medical condition often leads to cognitive impairments, unusual vital signs, and potentially visual hallucinations. The use of illegal drugs is frequently identified as the leading medical trigger for acute psychosis. Medical practitioners are advised to inquire about recent incidents of head injury or trauma, episodes of seizures, signs of cerebrovascular disease, or the emergence or exacerbation of headaches. 2 The gradual onset of psychosis may indicate a potential oncological origin. Gathering a comprehensive history from family members is crucial for a thorough understanding of the illness's onset and progression (Garrett, 2016). Schizophrenia is a multifaceted psychiatric disorder, often first identified through an initial psychotic episode—marked by a disconnection from reality—between the ages of 16 and 30 (NICE(National Institution for health and Care Excellence), 2014). Its symptoms are broadly divided into positive or negative categories. Positive symptoms encompass experiences like hallucinations, delusions, and erratic behaviors. In contrast, negative symptoms involve diminished emotional expression and a lack of motivation. Additionally, these symptoms may coexist with mood disorders, including depression or mania, leading to a diagnosis of schizoaffective disorder. Individuals suffering from schizophrenia frequently face challenges in social and occupational settings and may have difficulties with personal care (NICE, 2014). Recognized as a critical cause of disability worldwide, schizophrenia affects nearly 1% of the population globally (Moreno-Küstner et al., 2018). Since psychoanalysis emerged a century ago, there has consistently been a group of clinicians who advocated psychotherapy's application to psychosis. Among these pioneers, Paul Federn stands out as the first to extensively discuss the psychodynamics of psychosis, advocating for specialized adjustments in therapeutic techniques. ―Cognitive models of psychosis are an important link in this chain. They provide a psychological description of the phenomena from which hypotheses concerning causal processes can be derived and tested; social, individual, and neurobiological factors can then be integrated via their impact on these cognitive processes‖ (Garety et al., 2001). Over the past decade, there has been growing consensus on ―the importance of connecting phenomenological experiences with social, psychological, and neurobiological explanations to better comprehend psychosis symptoms‖. Cognitive models have emerged as a crucial intermediary in this endeavour, offering a psychological framework that allows for the hypothesis and verification of causal mechanisms. These models enable the integration of social, individual, and neurobiological influences through their effect on cognitive functions (Pillny & Lincoln, 2020). 3 Current therapeutic guidelines endorse a variety of psychotherapeutic methods for treating psychotic disorders, tailored to different treatment objectives. Cognitive Behavioral Therapy (CBT) is specifically recommended for addressing positive symptoms and overall symptoms across all stages of the disorder, without limitations (Tarrier, 2005). Yet, there remains a significant gap in our comprehensive understanding of the psychopathological underpinnings of psychosis, which would elucidate the therapeutic transformations observed. Psychopathology is ―the scientific exploration of abnormal mental states that, for more than a century, has provided a gestalt for psychiatric disorders and guided clinical as well as scientific progress in modern psychiatry‖. In the wake of the immense technical advances, however, psychopathology has been increasingly marginalized by neurobiological, genetic, and neuropsychological research. This ongoing erosion of psychiatric phenomenology is further fostered by clinical casualness as well as pressured health care and research systems. ―The skill to precisely and carefully assess psychopathology in a qualified manner used to be a core attribute of mental health professionals, but today's curricula pay increasingly less attention to its training, thus blurring the border between pathology and variants of the ―normal‖ further‖ (Schultze-Lutter et al., 2018). Cognitive Behavioral Therapy for Psychosis (CBTp) is recognized as an empirically validated method that has been shown to improve symptom control and functionality in individuals suffering from psychotic disorders. CBTp aims to enhance coping strategies for dealing with difficult symptoms and experiences, such as hallucinations, negative symptoms, cognitive impairments, and delusions (Landa, 2017). The development of CBTp can be attributed to Dr. Aaron Beck, an American psychiatrist renowned for founding Cognitive Behavioral Therapy. Beck's initial application of CBT in the outpatient treatment of patients with chronic schizophrenia and delusions in 1952 represents the inaugural use of CBT in psychosis (Beck, 1976). 4 Although the mechanisms of action are unclear but according to Drake (2020) researchers have explored:  Cognitive processes can be improved by modifying unhelpful thinking patterns, correcting inaccuracies in thought, shifting the focus of attention, and fostering constructive coping strategies.  Behavioral adjustments can be enhanced by familiarizing oneself with and subsequently diminishing unhelpful behaviors, through the process of habituation, the cessation of such behaviors, engagement in positive activities, learning through association, and encouraging beneficial behaviors.  Physiologically, a reduction in excessive arousal can be achieved through repeated exposure to stressors, training in responses that counteract stress, and alterations in the activity of the autonomic nervous system (K. Drake et al., 2020). Cognitive Behavioral Therapy (CBT) typically involves 10 to 20 weekly sessions, each lasting about an hour, which can be conducted on an individual basis, with family members, or within small group settings. Recently, there has been a rise in innovative approaches, including the use of Internet-based therapies and support through clinician- assisted computer programs (Lindenmayer, 2000). David (2018) outlines that Cognitive Behavioral Therapy (CBT) encompasses an array of therapeutic techniques, such as:  Psychoeducation: Equipping patients with knowledge to better comprehend mental health conditions.  Cognitive restructuring: The process of identifying negative thoughts, challenging their validity, and substituting them with more adaptive and realistic alternatives.  Exposure therapy: Aiming to decrease avoidance behaviors that reinforce anxiety through negative reinforcement, and promoting confrontational behaviors towards fears. 5  Behavioral activation: Encouraging participation in activities that are either enjoyable or beneficial (for example, exercising), and leaning on social support networks.  Relaxation methods: Acquiring and applying strategies to reduce physiological excitement, encompassing practices such as deep breathing exercises, guided visualization, progressive muscle relaxation, and concentration on immediate sensory experiences.  Homework assignments: Engaging in practices outside of therapy sessions to enhance the learning and application of coping strategies. Relapse prevention: Accepting minor setbacks as part of the process and devising strategies for coping with potential future stressors or symptoms by continuing to apply CBT techniques and creating proactive coping strategies. CBT has evolved to light the specific requirements of persons with particular mental health diagnoses, allowing for tailored treatment approaches (David et al., 2018). 1.1 Theoretical Models of Psychosis and CBTp 1.1.1 The ABC cognition model Beck asserts that CBT is effective through a collaborative process of identifying significant problems, examining one's habitual thought patterns about these problems, analyzing behavioral responses, and evaluating the helpfulness and realism of these thoughts and behaviors. The approach involves considering alternative, more beneficial ways of thinking and acting, experimenting with these new approaches, and adopting the strategies that prove to be effective. CBT is grounded in the principle that a person's emotional responses are shaped by their interpretation of events, as outlined in Beck's Model of Emotional Difficulties. This cognitive process is encapsulated in the ABC acronym, where:  A represents an activating event, which is any distinct and observable experience.  B denotes the beliefs about the event, encompassing both immediate thoughts and deeper beliefs. 6  C refers to the consequences, including emotional and behavioral responses that stem from these beliefs. Integral to this model are core beliefs, which are deep- seated perceptions about oneself and the world. These core beliefs can influence the thoughts and beliefs triggered by an activating event, further affecting the individual's emotional and behavioral responses (Beck, 1976). 1.1.2 The Stress-Vulnerability Model It is introduced by Zubin & Spring in 1977, forms a fundamental principle of the (CBTp. This model elucidates the interplay between stress levels and the manifestation of symptoms, and it aims to demystify unusual experiences by demonstrating that people, when subjected to varying degrees of stress, can exhibit such phenomena. According to this model, there exists a reciprocal relationship between stress and an individual‘s susceptibility to psychotic experiences. In essence, individuals more sensitive to certain stressors are at a higher risk of experiencing psychotic symptoms. This model comprehensively considers the role of biological factors, life stressors, pivotal childhood events, environmental influences, cognitive aspects, and deficits in reasoning and attribution. These elements together may precipitate psychotic episodes. Additionally, psychotic episodes can escalate stress levels, thus perpetuating a detrimental cycle where symptoms and stress exacerbate each other. Therefore, the primary objective of CBTp is to alleviate the distress associated with psychotic symptoms by altering the patients' perceptions and beliefs regarding the symptoms' nature and implications (Zubin & Spring, 1977). In CBTp, ―the therapeutic journey is envisioned as a sequence of critical steps designed to alleviate the patient's symptoms and impairments by transforming their beliefs regarding these symptoms as a result we can break the ongoing cycle where symptoms and stress exacerbate each other reaching recovery‖ (Landa, 2017). 1.2 Problem statement Schizophrenia carries considerable personal, social, and financial burdens, with an especially alarming impact on mortality (Olfson et al., 2015). Research has highlighted the stark reality that individuals diagnosed with schizophrenia tend to ―have their lives shortened by an average of 14.5 years compared to those without the condition‖ 7 (Hjorthøj et al., 2017). Further studies corroborate this finding, indicating a reduced life expectancy of 13 to 15 years for those affected by schizophrenia (Ali et al., 2023). Despite the effectiveness of antipsychotic medications, a significant fraction of patients—ranging from 10% to 60%—do not fully respond to these treatments, particularly concerning the persistence of positive symptoms (Butler et al., 2006). Approximately one-third of individuals diagnosed with schizophrenia exhibit inadequate responses to conventional antipsychotic treatment (Samara et al., 2019). Treatment-resistant schizophrenia is characterized by insufficient symptom reduction (less than 20%) despite undergoing treatment with at least two different antipsychotics, each at an appropriate dosage for a minimum of four weeks (Kane et al., 1988). This substantial challenge posed by medication-resistant symptoms has prompted clinicians and researchers to advocate for the exploration and development of supplementary therapeutic strategies. These strategies aim to bolster the efficacy of pharmacological treatments and enhance overall patient outcomes, with a particular focus on various psychotherapeutic interventions (Haddock et al., 1998). By the mid-1980s, the consensus among researchers and practitioners focusing on schizophrenia was that large-scale studies had demonstrated minimal to no effectiveness of supportive or psychodynamic psychotherapy in managing the condition and its associated symptoms. However, the body of research dedicated to the benefits of the CBT for addressing the positive symptoms of schizophrenia, which emerged during the same timeframe and continues to be explored, has not reached the same level of widespread recognition (Gunderson et al., 1984). Originally, CBT was developed to treat neurotic disorders, such as anxiety and depression, and its success in these areas is now firmly established. The foundational premise of CBT, regardless of the specific disorder it is applied to, is that both the emergence and persistence of symptoms or issues are influenced by cognitive and environmental factors. These factors can be altered through the introduction of more adaptive cognitive and behavioral strategies. The theoretical frameworks underpinning CBT's application vary in their level of development across different disorders, indicating that the approach is more thoroughly conceptualized and applied in some areas compared to others (Haddock et al., 1998). 8 Historically, it was believed that psychotic symptoms associated with schizophrenia spectrum disorders were impervious to psychotherapeutic interventions (Mueser & Berenbaum, 1990). However, in light of findings from various reviews and meta- analyses conducted in the following decade recently, CBT has been endorsed as a viable psychosocial intervention for individuals experiencing enduring psychotic symptoms (Dickerson, 2004; Gaudiano, 2005; Jones et al., 2012; Pilling et al., 2002; Pfammatter et al., 2006; Rathod et al., 2008; Rector & Beck, 2012; Wykes et al., 2008; Zimmermann et al., 2005). Therefore, this study is considered an important study because it will help us to understand the importance of psychotherapy in the treatment of hallucinations and delusions as this will enable us to intervene with the appropriate interventions and enhance recovery from mental illness in Palestine. 1.3 Significance of the Study This research represents the first exploration within Palestine into the efficacy of CBT in managing hallucinations and delusions among individuals diagnosed with schizophrenia. It aims to identify protective factors that are associated with significant improvements and reduced anxiety levels linked to these symptoms. Furthermore, the study will facilitate the forecasting of progressive treatment strategies for psychosis in schizophrenia patients, ultimately assisting them in achieving recovery. In order to accomplish these results our policy makers must consider providing CBT training programs for mental health institutions nurses in addition to establish centers that provides CBT by qualified and trained personnels and lastly to provide us community mental health nurses opportunities to work on our job description including more efficient services for mental health patients and the resources necessary for enduring further research. 1.4 Research Objectives 1. To assess the effectiveness of CBT on treatment of hallucinations and delusions among schizophrenia patients. 2. To determine if CBT contributes to lower levels of anxiety related to hallucinations and delusions compared to control group who received standardized treatment. 9 3. To determine if there is any significant difference between standardized treatment and treatment with CBT among patients with schizophrenia. 4. To determine the contributing factors affecting treatment outcomes. 1.5 Research Questions 1. Is CBT effective in the treatment of hallucinations and delusions? 2. Does the addition of CBT to the treatment of psychosis contribute to lower levels of anxiety and stress related to hallucinations and delusions contributing to improve quality of life? 3. Are there any statistically significant differences in the improvement of schizophrenia severity score among patients who are given treatment as usual alone and patients who are given both CBT and treatment as usual? 4. Are there any statistically significant differences in the levels of improvement of CBT with other independent variables including demographic variables? 1.6 Research Hypothesis 1. Using CBT is effective in treating hallucinations and delusions among patients with schizophrenia at a significance level of 0.05. 2. There is a relationship between the type of treatment and levels of anxiety related to hallucinations and delusions among patients with schizophrenia at a significance level of 0.05. 3. There are statistically significant differences in patients‘ improvement, who are given standardized treatment and those who are given both CBT and treatment as usual, at a significance level of 0.05. 4. There are no statistically significant differences in the levels of improvement with demographic variables at a significance level of 0.05. Historically, the perception of delusional beliefs has been distinct from that of normal beliefs, with challenging such beliefs considered futile and potentially harmful. Consequently, cognitive interventions were deemed inappropriate. However, a recent shift in 10 perspective has positioned delusional beliefs along a continuum with normal beliefs. This shift is supported by various evidence, including the relatively high prevalence of irrational or paranormal beliefs in nonpsychotic individuals, fluctuations in the intensity of delusional beliefs over time, and findings indicating that cognitive approaches can alleviate delusional conviction and distress (Gather et al., 2004). An examination focusing on the utility of the CBT as a supplementary approach for individuals with treatment-resistant schizophrenia (TRS) in various research cohorts found that, among eight qualified studies, five reported statistically meaningful success of CBT in diminishing positive psychotic symptoms in TRS. Additionally, findings suggest that to maintain these improvements, a follow-up duration of no less than six months after CBT application may be necessary. Thus, CBT is affirmed to be a secure and potent additional therapy for those battling this condition. As a result, it is advised that nurses in psychiatric units, emergency departments, and those involved in home health or community-based care receive CBT training (Ryan et al., 2022). Numerous scholars have tailored the principles of the CBT expressly for persons diagnosed with schizophrenia, with a focus mainly on enduring positive symptoms. Typically, these methods aid individuals in contextualizing their symptoms, positioning their psychotic experiences within the broader range of non-psychotic phenomena, and investigating the roots of their hallucinations (Nucifora et al., 2019). In a comprehensive review of a collection of meta-analysis and randomized controlled trials investigating family intervention models designed to prevent relapse in schizophrenia patients, including those incorporating CBT, were examined. The findings of the review revealed that all interventions, except crisis-oriented interventions and family psychoeducation comprising two sessions or fewer, significantly decreased the relapse rate compared to standard treatment at the primary 12-month timepoint (Rodolico et al., 2022). In previous meta-analyses, psychotherapies, particularly the CBT and interpersonal psychotherapy, have emerged as the foremost interventions when compared to psychological controls. Their effectiveness in treating various youth problems such as anxiety, attention deficit hyperactivity disorder, and conduct-related issues has been documented, albeit with modest mean effects after treatment (Zhou et al., 2020). 11 Research has identified specific brain sections, such as the dorsolateral prefrontal cortex and insula, as key predictors of CBT's success in managing panic disorders, indicating that enhanced activation in these areas during threat processing correlates with better treatment outcomes (Trkulja & Barić, 2021). Furthermore, early shifts in neural markers of anxiety have been observed during CBT, suggesting that these initial changes may underpin the therapeutic benefits seen in clinical practice (Reinecke et al., 2018). A randomized trial that provided the CBT to alleviate insomnia among a group of more than 3,000 university students concurrently observed a decrease in the occurrence of paranoid delusions and hallucinations in participants who experienced an improvement in their insomnia symptoms (Freeman et al., 2017). A significant study involving over 3,000 university students revealed that CBT aimed at reducing insomnia also inadvertently decreased the incidence of paranoid delusions and hallucinations among participants (Freeman et al., 2017). For individuals with schizophrenia, cognitive-behavioral therapy targeting psychosis symptoms (CBTp) has been proposed as a beneficial supplementary treatment to medication. While individual CBT sessions have been standard, the exploration of group-based CBT has shown comparable effectiveness in improving overall mental state and functioning, offering a potentially more cost-effective option (Guaiana et al., 2022). A randomized controlled trial assessing the impact of the CBT on psychotic symptoms was carried out in outpatient and inpatient mental health facilities across Mid-Norway. The trial included 45 patients. Findings indicated that 20 CBT sessions were markedly more effective than waiting list controls in improving the overall score on the Brief Psychiatric Rating Scale (BPRS), the delusions measure on the Psychotic Symptom Rating Scales (PSYRATS), and the Global Assessment of Functioning (GAF) symptom score upon conclusion of treatment. At the 12-month follow-up, only the GAF symptom score continued to show significant improvement across the entire sample. The research demonstrated that CBT administered by non-specialists in standard clinical environments can enhance positive psychotic symptoms, with some of these improvements persisting at the one-year follow-up. (Kråkvik et al., 2013). Another trial in the UK focused on schizophrenia patients resistant to clozapine, revealing that CBT, while not yielding long-term symptom relief, did result in statistically 12 significant, albeit clinically modest, improvements by treatment end without adverse effects (Morrison ClinPsyD et al., 2018). Exploring early-stage schizophrenia, a study found that CBT facilitated a quicker remission of symptoms compared to routine care, though this advantage did not persist into later stages (Lewis et al., 2002). The impact of CBT on anxiety-related psychotic symptoms was also analyzed, showing a medium to small significant effect post-treatment (Heavens et al., 2019). A trial comparing CBT to supportive psychotherapy for medication-resistant psychotic symptoms underscored CBT's modest but significant superiority in symptom improvement. This suggests CBT, even when delivered by clinical nurse specialists, could be an effective adjunct therapy for chronic psychosis (Durham et al., 2003). Additionally, CBT's potential benefits for schizophrenia symptoms unresponsive to clozapine have been highlighted, advocating for its consideration given the minimal associated risks and lack of alternative treatments (Todorovic et al., 2020). The advent of computerized CBT techniques, including Avatar therapy, has shown promising results in reducing the severity of auditory hallucinations, with some participants experiencing complete cessation of these voices (Leff et al., 2014). The incorporation of digital technology into Cognitive Behavioral Therapy (CBT) practices has significantly broadened the therapy's reach and utility, facilitating its deployment as a low-intensity resource for individuals with subclinical symptoms, an intermediary measure in stepped-care strategies, and an economical alternative for preventative initiatives (Biagianti et al., 2023). Remote delivery of CBT has also been explored, showing comparable efficacy to traditional face-to-face sessions in treating symptoms of OCD, depression, and anxiety, thus offering a feasible solution to increase access to treatment (Salazar de Pablo et al., 2023). 13 Chapter Two Methodology 2.1 Study Design and Sampling Technique A quasi-experimental trial design was used for the purpose of this study. The study was conducted from January-March 2023. The study sample consisted of 20 participants who met the inclusion criteria and were registered at Hebron mental health clinic, patients were assigned into two groups:  Control group: 10 patients continued to take treatment as usual.  Cases group: 10 patients continued to take treatment as usual in addition to 10 sessions of CBT. 2.2 Inclusion and exclusion criteria The selection criteria for the study include individuals aged between 16 to 30 years, in line with findings from the existing body of research that suggests a U-shaped trajectory in the progression of insight impairment. This pattern indicates severe insight impairment at the onset of the first psychosis episode, a modest improvement through midlife, and a subsequent decline in later years (Gerretsen et al., 2014), Participants should be diagnosed with schizophrenia and undergoing treatment. This stipulation is based on evidence indicating that an untreated psychosis duration exceeding one year correlates with less favorable outcomes (Harris et al., 2005). Additionally, candidates must not have intellectual disabilities, abstain from drug or alcohol use, and currently experience both hallucinations and delusions. 2.3 Study Setting We selected all clients from Hebron mental health clinic which is the only psychiatric facility in Hebron to include clients from different representative areas of Hebron. It is a governmental institution with a multidisciplinary staff, including psychiatrists, psychologists, nurses and social workers. It provides mental health assessment for diagnosis of patients and regular pharmacological prescriptions and provides certain medications covered by health insurance. On the other hand, it doesn‘t provide any type of 14 psychotherapy, regular psych evaluation or home visits for their regular patients, mostly a family member of the patient comes to take their medication every month. 2.4 Study Instrument 2.4.1 The Psychotic Symptom Rating Scales (PSYRATS) The Psychotic Symptom Rating Scales (PSYRATS) consist of structured interviews segmented into two parts, aimed at evaluating auditory hallucinations and delusions. The section on auditory hallucinations includes an 11-item scale crafted to assess different facets of hallucinations, including their frequency, duration, severity, the intensity of distress they cause, and more nuanced features such as their controllability and the individual‘s perceptions regarding the origins of the voices. This scale utilizes a five-point ordinal system for scoring symptoms, from 0 to 4. The selection of items was informed by extensive interviews with patients experiencing hallucinations and by insights from psychological interventions for psychotic patients. The delusions segment contains a six-item scale that evaluates the dimensions of delusions, drawing upon phenomenological research and psychological treatment practices. This section also employs a five-point ordinal scoring system (Haddock et al., 1999). Overall, the PSYRATS, with its 17 items, provides a detailed quantification of the specific dimensions of hallucinations and delusions, using a scoring range from 0 (absent) to 4 (severe), facilitating a comprehensive symptom severity assessment (Cowie, 2015). A study investigating the PSYRATS' reliability, validity, and structural integrity involved 257 subjects with acute first episodes of schizophrenia or related disorders. Although the PSYRATS has been validated for use in patients with chronic psychosis, its application in first-episode patients required further examination. The study confirmed the PSYRATS' reliability and validity, including its sensitivity to change and its correlation with the PANSS, revealing two factors for delusions and three for hallucinations, thereby establishing its usefulness alongside existing measures of symptom severity (R. Drake et al., 2007b). In an Egyptian quasi-experimental study, the PSYRATS was utilized to ―examine the effect of acceptance and commitment therapy on auditory hallucinations in schizophrenia patients‖. An Arabic version of the PSYRATS was evaluated for its translation accuracy, content validity by a panel of experts, and test-retest reliability on a sample of fifteen patients, 15 yielding a significant correlation coefficient, thus affirming the scale's reliability for this study (R. Drake et al., 2007a). A quasi-experimental research project conducted in Egypt examined the "Impact of Acceptance and Commitment Therapy on Auditory Hallucinations in Schizophrenia Patients," utilizing the Arabic version of the Psychotic Symptom Rating Scales (PSYRATS). The PSYRATS, specifically for auditory hallucinations (PSYRATS-AH), were translated into Arabic. This translation and its content validity were evaluated by a panel of five experts in psychiatric nursing, leading to necessary adjustments. To ensure reliability, a test- retest procedure was carried out with the PSYRATS-AH on fifteen schizophrenia patients, adhering to predetermined inclusion criteria. The reliability analysis employed the nonparametric Cronbach's alpha, akin to the Pearson correlation coefficient, with a significance threshold set at p ≤ 0.07. This procedure confirmed a noteworthy reliability coefficient of 0.70 for the Arabic PSYRATS, indicating a substantial consistency over time (El Ashry et al., 2021). 2.4.2 Positive and Negative Syndrome Scale (PANSS) The Positive and Negative Syndrome Scale (PANSS) was created as a comprehensive 30- item rating tool, incorporating 18 items from the Brief Psychiatric Rating Scale (BPRS) and 12 from the Psychopathology Rating Schedule (PRS). Conducting a patient interview using the PANSS typically takes between 30 to 40 minutes, collecting data necessary to evaluate the patient's psychopathological state over the preceding week. The PANSS provides exhaustive definitions for each item, along with specific criteria for each of the seven scoring levels: ―1 = absent, 2 = minimal, 3 = mild, 4 = moderate, 5 = moderate–severe, 6 = severe, and 7 = extreme‖. Within this 30-item framework, there are seven items dedicated to assessing positive symptoms, seven for negative symptoms, and sixteen for general psychopathology. The scoring scale from 2 to 7 denotes progressively increasing intensity of symptoms (Kay et al., 1988). Being classified as "mildly ill" is roughly equivalent to a total PANSS score of 58, while a score of 75 indicates being "moderately ill," a score of 95 suggests being "markedly ill," and a score of 116 denotes being "severely ill." In terms of the Clinical Global Impressions (CGI) scale, being considered "minimally improved" correlates with an average PANSS 16 reduction of 19%, with further increments of improvement at 23%, 26%, and 28% respectively (Leucht et al., 2005). A research project conducted in Qatar evaluated the accuracy and dependability of the Arabic adaptation of the PANSS. This version was crafted using a meticulous back-translation process into formal Arabic. The study recruited 101 Arab individuals diagnosed with schizophrenia, alongside 98 Arabs without any mental health diagnoses, serving as controls. Diagnoses were verified or excluded using the Arabic rendition of the Mini International Neuropsychiatric Interview (MINI-6). The study's focus was on determining the reliability of the PANSS. Furthermore, the construct validity of the PANSS was examined by aligning its total scores with those from the Clinical Global Impression-Severity scale, utilizing the MINI-6 as a comparative benchmark. The results demonstrated robust internal consistency (0.92) for the PANSS, with patient scores significantly surpassing those of the control group, indicating the scale's sensitivity. Both inter-rater and test-retest reliabilities were found to be high (0.92 and 0.75, respectively), underscoring the tool's reliability over time and across different assessors. The PANSS's strong sensitivity and specificity, when compared to the MINI-6, highlighted its valid construct in this context. Ultimately, this study affirmed the Arabic version of the PANSS as a trustworthy and valid tool for evaluating schizophrenia within the Arab demographic (Yehya et al., 2016). 2.5 Procedure The objectives of the CBT for psychosis encompass diminishing the frequency of symptoms, alleviating related distress, and minimizing the impact on the individual's daily functioning and overall quality of life. Within this framework, the cognitive aspects of CBT for psychosis are designed to equip individuals diagnosed with schizophrenia with the skills to recognize and observe their thoughts and beliefs in given situations. Furthermore, it aims to guide these individuals in assessing and adjusting their thoughts and beliefs in light of objective external evidence and real-life contexts (Hagen et al., 2013). 17 To achieve this objective, the PSYRATS and the PANSS were employed by the student researcher only pre and post intervention as the mental health clinic team didn‘t have time to assist the researcher, and the supervisor had full time lectures in the University which is very destined but he was continuously following up with the student on daily basis. Both of the used tools have been validated for their reliability and accuracy within the Arabic population. These tools can be effectively utilized in both Arabic and English, yielding consistent results. The English version was chosen with an objective rating by the researcher according to the assessment. Anxiety levels were gauged using the initial and final interviews through specific sections of the PSYRATS scale: Section 8 (amount of distress) and Section 9 (intensity of distress) for auditory hallucinations, and Sections 4 (amount of distress) and 5 (intensity of distress) for delusions, as detailed in Appendix D. Additionally, the general psychopathology scale items G2 (anxiety) and G4 (tension) of the PANSS rating scale were used to measure anxiety levels, as outlined in Appendix E. During the sessions, stress levels were reassessed, and adjustments were made to enhance stress coping strategies. Structured interviews based on these scales were conducted in the first session for assessment, followed by nine CBT sessions as per the guidelines for the CBTp, detailed in an introductory manual for clinicians. These sessions were overseen by Dr. Adnan Sarhan, a mental health specialist with a CBT certification. Consent was obtained to explain the study's purpose from the spouses of clients lacking insight and directly from the clients themselves when insight was present. These sessions took place from January to March 2023 at the Hebron psychiatric health clinic, which was accessible to the clients. However, the final three sessions for clients (J.N., I.A., A.N., F.W., A.H., H.A.) were conducted at their homes due to their inability to travel to the clinic. Each session lasted approximately 45 minutes, occurring twice weekly for each client by the student researcher who was trained and supervised by Dr. Adnan Sarhan. Maintaining the structured framework of CBTp in each session was vital for several reasons: it enhanced predictability, reducing anxiety; it fostered greater patient engagement and involvement in their treatment; it supported the exercise of memory and metacognitive skills; and it provided a model for functional behavior. 18 Below is the CBTp session structure I adhered to in my research, according to Landa (2017): At the beginning of each session, the client and I would:  Conduct a mental health assessment.  Assess symptom severity.  Establish the session agenda.  Determine the order of topics for discussion. During the session, I would:  Review any homework assignments (if applicable).  Monitor progress and manage transitions throughout the session.  Connect the topics discussed to those from previous sessions and the overall treatment agenda. In the final minutes of the session, we would:  Summarize the topics discussed.  Plan for the next session.  Solicit the patient's feedback on the session (identifying what was helpful and what was not) to encourage their active participation in the treatment process.  Perform a final mental health status assessment.  Review and assign homework for completion before the next session. From the onset of the CBTp engagement stage, which persisted throughout the therapeutic process, I focused on developing rapport with the patient, enhancing their trust and openness, and encouraging them to participate in CBT sessions (Landa, 2017). Upon gathering the data, it was securely stored in a locker accessible solely by the researcher to ensure confidentiality and security. Avasthi (2020) emphasizes that establishing a robust therapeutic alliance is crucial in cognitive-behavioral therapy for psychosis (CBTp), 19 particularly because individuals experiencing psychosis may not be accustomed to discussing their experiences in a therapeutic setting. A reliable and trustworthy therapeutic relationship serves as a pivotal element in motivating the patient to engage with the CBTp process. Therefore, I adopted a supportive and understanding approach, while consciously avoiding confrontation or attempts to rationalize the clients' delusional or hallucinatory experiences during the early sessions. It was observed that some clients chose to remain silent during the initial session, a situation I approached with acceptance without pressuring them to speak. Despite encountering behaviors or attitudes from clients that could be perceived as unusual or amusing, I preserved my professionalism, refraining from any form of ridicule. Efforts were made to bolster the patients' self-esteem through various means, including encouragement of personal grooming, adherence to activities and instructions mutually agreed upon, acknowledgment of positive achievements or significant life events, and reinforcement of their strengths. Importantly, I refrained from making any unrealistic promises, recognizing that such actions could undermine the therapeutic alliance. Researcher used the following techniques according to Landa (2017): 2.5.1 Engagement All possible efforts were made to gain the trust of the clients throughout all the sessions. The approach involved:  Eliciting and exploring the clients' perceived available options for action.  Suggesting additional options for action that the clients might not have considered, while allowing them the autonomy to make their own decisions.  Discussing the clients' views on the positive and negative aspects of these options.  Highlighting potential benefits and drawbacks of the options that the clients may have overlooked.  Identifying any discrepancies between the client's current or planned behavior and their broader values and goals. 20  Emphasizing and reinforcing adaptive attitudes and behaviors by selectively reflecting, summarizing, and encouraging the client to elaborate on their adaptive attitudes. This could include the use of paradoxical interventions or role changes, such as asking the client to take on the role of the therapist.  The aim is to normalize experiences to prevent catastrophic or stigmatizing thoughts regarding mental health. It is important to acknowledge that psychotic experiences can be shared by individuals who are not ill and are part of a continuum with normal experience. This phase aims to empower clients with the confidence that they have the necessary skills for improved engagement in social and community activities. Through practicing new skills within a group environment and strategizing their application in real-life situations, clients build self-assurance and are motivated to participate in activities they once shunned. Integrating conversations about confidence, the dynamics of avoidance, and techniques for surmounting these challenges into programs focused on recovery may assist those with schizophrenia in enhancing their interpersonal and social capabilities (Bennett et al., 2023). 2.5.2 Assessing Psychotic Experiences In the second sessions conducted for eight clients, I assessed psychotic features using our study instruments in addition to comprehensive exploration of each psychotic symptom, covering aspects such as form, content, frequency, duration, typical conditions of occurrence, consequences, impact, attributed meaning, conviction in this meaning, quality, intensity, distress, and preoccupation. Following this, I filled the rating scores for the PANSS and PSYRATS scales to each client. Two clients (client A.I, client J.N) remained silent during the first session, prompting me to extend the engagement phase into the second session. Their assessments were then conducted in the third session, after establishing a rapport. 2.5.3 Recognizing Problems During the third and fourth sessions, in accordance with CBTp guidelines, we identified problems through various activities, ensuring the clients took the lead in the therapeutic process and maintained a collaborative approach to discussing issues: 21  Emphasizing the stress experienced by clients as a means to foster further discussion and exploration.  Normalizing and validating specific experiences to create a safe environment for clients to discuss issues without fear of judgment. I showed empathy when clients discussed difficulties in their lives and past events they believed influenced their thought patterns.  Comparing the clients' perspectives with those of significant individuals in their lives and examining possible reasons for any discrepancies. I communicated with my clients' relatives to differentiate reality from delusions. Clients J.N, A.I, G.N, F.W, and A.H exhibited persecutory delusions towards family members.  Indicating that some experiences reported by the clients or certain behaviors observed or reported to the therapist might be seen as problems requiring solutions.  Pointing out contradictions between the clients' denial of problems and other statements or actions, for instance, although all clients denied having a psychiatric illness, they acknowledged feeling better when taking their medication or during hospitalization. Thus, we addressed the stigma issue contributing to their denial of schizophrenia. Our objective was to empower clients, reduce stress during discussions of stressful situations, and help them recognize issues they could address after learning new coping mechanisms and problem-solving techniques in the psychiatric hospital. After determining a list of problems for each client, we collaboratively established short- term goals, including identifying stressful situations as they arise, recognizing emotions, enhancing self-care behaviors, improving social relationships, boosting self-esteem, concentrating on strengths, and pinpointing triggers for hallucinations and delusions. Long- term goals focused on learning to accept past traumatic experiences, enhancing social engagement, developing insight towards their illness and treatment, understanding their hallucinations and delusions, and adopting a realistic perception of the world, alongside other objectives tailored to each client's specific issues. 22 2.5.4 Interventions From the fourth to the eighth session, interventions were chosen and implemented for each client based on their individual goals and case formulations. Having established rapport and trust in the earlier sessions, we began to introduce a variety of intervention strategies. These included collaborating with clients to identify and mitigate triggers, aiding them in gathering evidence to support or refute their beliefs, setting up reality testing and behavioral experiments, educating them on cognitive distortions, teaching reasoning skills, and addressing core beliefs and automatic thoughts. During these intervention sessions, I maintained flexibility and also supported clients with tasks unrelated to therapy that contributed to broader objectives and improved their quality of life. This assistance ranged from helping with job applications (for A.I.), university applications (for A.N.), to enhancing resumes, and encouraging family support by talking to family members alone after the sessions to inform them of the progress and patients willing and goals to facilitate their achievements of goals including: work, academic pursuits, or community engagement. My overarching role in CBTp was to foster a therapeutic alliance, allowing clients to steer the process, define treatment goals, encourage the completion of homework, provide structure, understand the clients' beliefs, safeguard and boost self-esteem, and guide clients toward discovering their most effective coping strategies. Concurrently, I refrained from imposing my perspective, adopting an overly authoritative stance, trivializing the client's experiences, or being interpretive or inconsistent. Additionally, we engaged in role-playing during sessions to aid clients in practicing new coping mechanisms and re-engaging with the community. After outlining general intervention strategies for all clients, I began addressing delusions, followed by hallucinations, tailoring the approach to each client's specific psychotic experiences in accordance with CBTp guidelines (2017), as I will detail. A. Working with Delusions After conducting a detailed assessment of beliefs using the PANSS and PSYRATS scales applied in the previous session, we gained a comprehensive understanding of the client's belief structure. Subsequently, a formulation was collaboratively developed with the client. 23 We balanced the reasons for adopting the belief against the reasons for maintaining it, which proved beneficial in establishing a foundation from which we could challenge the faulty belief. Re-evaluating beliefs Delusion often arises as a response to perplexing or alarming situations, leading individuals to seek understanding in moments of fear, anxiety, or confusion. Providing alternative interpretations can alleviate these emotional states. Therefore, it became crucial to assist individuals in re-examining the evidence they had brought forward, beginning with the justification for their delusional thoughts on a daily basis. Offering different perspectives on the clients' beliefs, while carefully highlighting any inconsistencies and logical errors in their belief system, proved beneficial. These alternate explanations were either introduced by me or derived from discussions with the clients in earlier sessions. Through this joint effort, clients were prompted to evaluate their delusional convictions and other possible explanations against the backdrop of the evidence at hand. Reality testing The client was stimulated to engage in specific behaviors to test the validity of their belief. They were prompted ―to make predictions about external events so that the outcomes of these events could serve as tests of those predictions‖. Together with the client, researcher developed an experiment. researcher used the "3 Cs" to teach clients to start practicing reality testing independently (Landa, 2017): Catch It  What is the spontaneous thought?  What was the patient thinking in their mind?  Is this thought helping the client to achieve his goal? 24 Check It  How did it affect the patient‘s feelings or actions?  What evidence supports or contradicts this thought?  What would the patient say to a friend who had this thought?  Is this thought a result of cognitive distortion (e.g., jumping to conclusions; black-and- white thinking)? Change It  What is an alternative perspective or possibility?  Is there another way to think about this situation?  Does adopting a new thought help the patient to achieve his goal? None of my clients could prove that their evidence was true so we made a reality check list and we made an agreement that they will apply it when they are stressed, angry or frightened about an idea and that they will not assume certain explanations for events instead they will focus on their strength points and practice new coping mechanism that we learned, also we agreed on a homework that they will right any disturbing idea, in case they couldn‘t test it by our reality checklist they will ask for help from a trusted person in their house or me in the next session when we review this homework, also they will right situations in which they felt happy, anxious, sad and frightened and what they thought during these situations. Verbal Challenges of Delusions The investigator approached the task of questioning clients' delusions with a gentle and non- threatening demeanor. By subtly highlighting the discrepancies within the clients' belief frameworks, the researcher subsequently prompted the consideration of different interpretations of the evidence. When appropriate, the researcher also softly proposed alternative viewpoints. Clients were then motivated to compare their delusional perceptions with these alternative perspectives, considering the evidence available. 25 Normalizing Cognitive Processes To help clients comprehend and address delusions, the researcher explained that a delusion typically stems from an attempt to make sense of confusing or intimidating experiences, such as hearing voices or feeling panicked. Thus, the researcher portrayed the delusion as an understandable effort to impose meaning in times of fear or anxiety, noting its initial role in reducing confusion and alleviating fear. The goal was to transition from this unhelpful coping strategy to a more adaptive method of handling these experiences. B. Working with Hallucinations Our aim was ―to work with distress caused by voices by exploring beliefs about the voices. Voices themselves do not cause distress. Rather, the presence of voices influences beliefs regarding the voices, which in turn cause distress‖ (Chadwick, 2008). After using our assessment tools (PANNS and PSYRATS) to understand the nature of hallucinations, 6 of my clients were having only auditory hallucinations and the other 4 were having auditory and visual hallucinations. Utilizing Beck‘s ABC model of cognition (1976), researcher started with ―the consequence (C), then worked back to activating event (A), then explored the belief (B)‖. During this process, the following was considered when working with hallucinations, me and the clients collaborate to:  Gently challenge beliefs about voices.  Establish the identity of voices and visions (malevolent or benevolent).  Understand the power of voices.  Learn how to control the voices.  Recognize resistance or compliance to the voices.  Uncover the origins of the voices. 26 One way to do this is through reality testing (e.g., I asked if others can hear them and I asked the clients to tape record the voices or filming the visions). I used these aspects of the therapeutic process in working with hallucinations: Introduce normalizing alternatives I conveyed the message that experiencing hallucinations is compatible with leading a normal, productive, and happy life. Additionally, I mentioned famous and successful individuals, including some actresses and singers, to inspire hope and provide reassurance about the clients' future well-being and recovery. The goal was to assist in the appropriate attribution of hallucinations All my clients demonstrated that assessed hallucinations were associated with anxiety or a depressed mood. Therefore, techniques for managing anxiety and depression were employed to target associated symptoms first. Examine the content of voices / visions The researcher gathered contextual evidence to explore the beliefs, fears, and meanings underlying the hallucinations. For example, my clients G.A.N, G.S.N, and H.A all heard voices with negative content about their appearance, which was attributed to their low self- esteem. My clients F.W, A.H, and N.S experienced erotomanic delusions, attributed to a lack of love and their experiences of divorce. My client A.I also had erotomanic delusions, but these were linked to his experiences of loss and trauma. G.S.N, T.H, A.H, and I.A experienced persecutory delusions, which were attributed to their sense of fear and lack of trust. G.A.N and H.A also had jealous delusions due to low self-esteem and feelings of unworthiness. Enhance coping During intervention sessions, the clients and I worked to improve existing coping techniques and to discover new ones. An example of the coping strategies for auditory hallucinations we had employ included self-monitoring, whereby clients were assigned homework to write diaries focusing on stress triggers and hallucination triggers, anxiety reliving techniques, and distraction techniques such as talk, listening to music, going for a walk, reading the Quran, or praying for religious 27 clients like I.A, H.A, and T.H. Another coping technique involved focusing on cognitive distortions—maladaptive beliefs about hallucinations—and attempting to respond to hallucinations rationally. Clients also worked on dismissing negative voice content by confronting it and listing evidence for and against the content of the hallucination. This intervention, when practiced for ten minutes daily, has been shown to decrease distress among 8 of my clients. Other aspects of focusing include reminding oneself that the voices or visions are not perceived by others and allocating a ten-minute daily time slot for the hallucinations. In each session, I reassessed and made changes to the intervention based on the level of improvement. Two of my clients (N.S and J.S.N) were in a stupor, and coping techniques were ineffective because the voices had clear meaning, represented a long-standing relationship, and the hallucinations possessed malevolent power. C. Relapse Work and termination In the ninth and tenth sessions, we initiated relapse work to ensure that the client feels confident in their ability to use skills and techniques to manage psychotic symptoms. I began by assessing previous relapses, which involved the following considerations:  What is the form, content and duration of the previous relapses?  What are antecedents of the previous relapse?  What is the client ‗s appraisal of this experience?  What is the impact of previous relapse? Additionally, I assessed for early warning signs and triggering events for relapse, introducing examples  What events led to it?  How and to what extent was the client able to control himself during the relapse?  Are there any aspects of the relapse that client finds exciting or rewarding (some of my clients enjoyed the sensation of finding the world ‗s answers (A.I), beautiful hallucinations (N.S), get attention from family (F.W, A.H, G.N))? 28 Finally, I assessed the client's relapse cognitions to develop a relapse prevention plan. The plan is based on the client's understanding of the relapse process, as well as their thoughts, assumptions, and beliefs about relapse. Our objective was to create a mutual psychological comprehension of the client's pattern of relapse. Following the evaluation of relapse risk and the creation of a conceptual framework, we formulated personalized strategies for preventing relapse, rooted in this framework. Techniques from Cognitive Behavioral Therapy (CBT), acquired in earlier sessions, were employed to confront and reassess dysfunctional thinking related to relapse. We then reviewed the client's current use of self-regulatory strategies and made a plan for their continued use in the future. I also discussed with the client and their family how to monitor warning signs and predict a relapse. Finally, we addressed difficulties in implementing the plan and collaborated with the client to resolve any foreseeable problems. Elements of CBT for Psychosis are included in Appendix F below. 2.6 Ethical considerations The Ethical considerations and the approval of the An-Najah Institutional Review Board (IRB) was insured before starting the research (Ref:Mas.Sep.2022\26), the Palestinian ministry of health and Hebron ministry of health permissions were obtained, and a permission from the spouse of the clients as they are incompetent due to their mental illness were obtained after providing an information sheet to explain the aim, the participants role in the study and issues of confidentiality and voluntary participation but their spouse refused voice recording of the sessions. 2.7 Data Analysis The collected data was analyzed by the Statistical Package for Social Sciences (SPSS) Version (28). Data entry was performed by the researcher and double-checked for outliers or errors. Data was tested for normality using the Kolmogorov-Smirnov test. the Kolmogorov-Smirnov test shown that the data is normally distributed (p=>0.05). Data analysis of descriptive and inferential statistics was conducted. Regarding descriptive statistics, frequency, percentages, mean score, Standard Deviation (SD) and Chi-square test were used to describe the study variables. Regarding inferential statistics, data was tested for normality, a parametric test including the independent t- 29 test was used to assess the effectiveness of CBT treatment in terms of the auditory hallucinations, distress, delusion, anxiety and schizophrenia severity scores. 30 Chapter Three Results 3.1 Introduction This chapter details the frequency and percentages of the demographic characteristics of the participants, as well as the differences between the two groups in terms of demographic variables. Furthermore, it evaluates the effectiveness of CBT treatment among participants concerning auditory hallucinations, delusions, and the severity scores of schizophrenia 3.2 Demographic Characteristics of the participants Table 1 outlines the socio-demographic characteristics of participants in both groups. There were no significant differences between the experimental and control groups regarding demographic variables. The majority, two-thirds of participants in both groups, were aged between 15-29 years. In terms of gender, over two-thirds of the participants were female, constituting 75%, while males represented 25%. Concerning education, 60% of the participants had obtained a Bachelor‘s Degree, 35% had completed secondary school, and 5% had finished primary school. More than half of the participants reported a family history of psychiatric disorders. Employment status revealed that 80% of participants were unemployed, whereas 20% were employed. Regarding suicidal and homicidal potentials, 80% of participants did not exhibit such tendencies, while 20% did. Further details are provided in Table 1. 31 Table 1 Socio-demographic characteristics of the participants (n=20) Chi-Square Test, *Significant at p<0.05 Socio-demographic Characteristic‘s Experimental Group (n=10) Control Group (n=10) Total (n=20) X 2 (df) P-value n % N % n % Age Group 15-29 years old 7 70.0% 6 60.0% 13 65.0% .220 (1) 0.639 30-44 years old 3 30.0% 4 40.0% 7 35.0% Gender Male 2 20.0% 3 30.0% 5 25.0% .267 (1) 0.606 Female 8 80.0% 7 70.0% 15 75.0% Place of Resident Village 5 50.0% 3 30.0% 8 40.0% .944 (2) 0.624 City 4 40.0% 5 50.0% 9 45.0% Camp 1 10.0% 2 20.0% 3 15.0% Level of Education Secondary school 5 50.0% 2 20.0% 7 35.0% Bachelor‘s Degree or higher 4 40.0% 8 80.0% 12 60.0% Marital status Married 5 50.0% 2 20.0% 7 35.0% 1.986 (2) 0.371 Single 3 30.0% 5 50.0% 8 40.0% Divorced or Widowed 2 20.0% 3 30.0% 5 25.0% Past Medical History Yes 0 0.0% 3 30.0% 3 15.0% 3.529 (1) 0.211 No 10 100% 7 70.0% 17 85.0% Month Income <400$ 6 60.0% 3 30.0% 9 45.0% 1.818 (1) 0.370 ≥400$ 4 40.0% 7 70.0% 11 55.0% Family History of Psychiatric disorder Yes 5 50.0% 2 20.0% 7 35.0% 1.978 (1) 0.350 No 5 50.0% 8 80.0% 13 65.0% Working Status Employed 0 0.0% 4 40.0% 4 20.0% 5.00 (1) 0.087 Not Employed 10 100% 6 60.0% 16 80.0% Addictive behavior and habits Smoking Cigarette 4 40.0% 3 30.0% 7 35.0% .220 (1) 0.639 None 6 60.0% 7 70.0% 13 65.0% Using drugs 0 0% 0 0% 0 0% Drinking alcohol 0 0% 0 0% 0 0% Suicidal and homicidal potentials Yes 0 0.0% 4 40.0% 4 20.0% 5.00 (1) 0.087 No 10 100% 6 60.0% 16 80.0% 32 3.3 Effectiveness of CBT treatment on auditory hallucination and on the intensity and amount of distress in auditory hallucinations domain among participants Table 2 demonstrates the effectiveness of CBT treatment on auditory hallucinations, including the intensity and level of distress in the auditory hallucinations domain among participants, utilizing the independent t-test. There was no significant difference in the hallucinations sum score between the intervention group (M=30.60, SD=2.836) and the control group (M=31.90, SD=5.933) (t=-0.625, p=0.540) in the pre-test. However, for the post-test hallucinations sum score, a significant difference was observed between the intervention group (M=21, SD=3.681) and the control group (M=32.2, SD=5.921) (t=- 5.079, p<0.001), indicating that participants who received CBT experienced a greater decrease in the auditory hallucinations sum score compared to those in the control group (Mean difference = 11.20). Regarding the post-test amount of distress sum score, a significant difference was found between the intervention group (M=1.70, SD=0.674) and the control group (M=3.30, SD=0.823) (t=-4.753, p<0.001), suggesting that participants who received CBT showed a reduced amount of distress sum score compared to those in the control group (Mean difference = 1.60). The data also reveals the effectiveness of CBT treatment on the intensity of distress within the auditory hallucinations domain, as analyzed through the independent t-test. A significant difference emerged between the intervention group (M=1.60, SD=0.699) and the control group (M=3.30, SD=0.823) (t=-4.977, p<0.001), indicating that CBT recipients exhibited a lower intensity of distress sum score compared to the control group participants (Mean difference = 1.70). 33 Table 2 The Effectiveness of CBT treatment on Auditory hallucinations and on the intensity and amount of distress in auditory hallucinations domain among participants (n=20) N Mean SD Statistical values Mean Different P-value Pre-test Auditory Hallucinations Sum Score Interventional group 10 30.60 2.836 t=-.625 df=18 1.30 .540 Control group 10 31.90 5.933 Post-test Auditory Hallucinations Sum Score Interventional group 10 21.00 3.681 t=-5.079 df=18 11.20 <.001* Control group 10 32.20 5.921 Post-test amount of distress mean score Interventi onal group 1 0 1.70 .674 t=-4.753 df=18 1.60 <.001* Control group 1 0 3.30 .823 Post-test intensity of distress mean score Interventional group 10 1.60 .699 t=-4.977 df=18 1.70 <.001* Control group 10 3.30 .823 Independent t-test, Min score 0, Max score 44, higher mean score means higher Auditory Hallucination. *Significant at p=<0.05, Independent t-test, Min score 0, Max score 4, higher mean score means higher amount and intensity of distress, *Significant at p=<0.05 34 Figure 1 The Effectiveness of CBT treatment on Auditory hallucinations among participants (n=20) 3.4 The effectiveness of CBT treatment on delusions and the amount and intensity of distress in delusion domain among participants Table 3 illustrates the effectiveness of CBT treatment on delusions and its impact on the amount and intensity of distress within the delusion domain among participants, as analyzed using the independent t-test. Regarding the delusion pre-test sum score, there was no significant difference between the intervention group (M=19, SD=3.197) and the control group (M=18.5, SD=2.708) (t=0.368, p=0.717). For the delusion post-test sum score, a significant difference was observed between the intervention group (M=13.7, SD=2.584) and the control group (M=19, SD=5.921) (t=- 4.478, p<0.001), indicating that participants who received CBT exhibited a reduced delusion sum score compared to those in the control group (Mean difference = 5.30). 30.6 31.9 21 32.2 Interventional group Control group Interventional group Control group Pre-test Auditory Hallucinations Sum Score Post-test Auditory Hallucinations Sum Score The Effectiveness of CBT treatment on Auditory hallucinations among participants 35 In terms of the amount of distress post-test sum score, a significant difference was found between the intervention group (M=2.20, SD=0.632) and the control group (M=3.30, SD=0.674) (t=-3.761, p<0.001), suggesting that participants who received CBT experienced a decreased amount of distress sum score in the delusion domain compared to those in the control group (Mean difference = 1.10). Regarding the intensity of distress post-test sum score, a significant difference was noted between the intervention group (M=2, SD=0.471) and the control group (M=3.20, SD=0.918) (t=-3.674, p=0.002). This indicates that participants who received CBT demonstrated a reduced intensity of distress sum score in the delusion domain compared to those in the control group (Mean difference = 1.20). Table 3 The effectiveness of CBT treatment on delusions and the amount and intensity of distress in the delusion domain among participants (n=20) N Mean SD Statistical values Men Different P- value Pre-test Delusion Sum Score Interventional group 10 19.00 3.197 t=.368 df=18 0.50 .717 Control group 10 18.50 2.877 Post-test Delusion Sum Score Interventional group 10 13.70 2.584 t=-4.478 df=18 5.30 <.001* Control group 10 19.00 2.708 Post-test intensity of distress mean score Interventional group 10 2.00 .471 t=-3.674 df=18 1.20 0.002* Control group 10 3.20 .918 Post-test amount of distress mean score Interventional group 10 2.20 .632 t=-3.761 df=18 1.10 <.001* Control group 10 3.30 .674 Independent t-test, Min score 0, Max score 24 higher mean score means higher delusion. Min score 0, Max score 4, higher mean score means higher amount and intensity of distress, *Significant at p=<0.05 36 Figure 2 The Effectiveness of CBT treatment on delusion among participants (n=20) 3.5 Effectiveness of CBT treatment on schizophrenia severity and anxiety in the Schizophrenia Severity domain Among Participants Table 4 shows the effectiveness of CBT treatment on schizophrenia severity among participants using the independent t-test. Regarding the schizophrenia severity pre-test sum score, there is no significant difference between interventional group (M=111.20, SD= 21.698) and control group (M=115.40, SD=13.599) (t=-0.519, P=0.610). Regarding the schizophrenia severity post-test sum score, there is a significant difference between interventional group (M=84.10, SD= 24.587) and control group (M=118.20, SD=14.061) (t=-3.807, p=<0.001). This means participants who received CBT have shown decreased schizophrenia severity sum score than those in control groups (Mean difference = 34.10). 19 18.5 13.7 19 Interventional group Control group Interventional group Control group Pre-test Delusion Sum Score Post-test Delusion Sum Score The Effectiveness of CBT treatment on Delusion among participants 37 It also shows the effectiveness of CBT treatment on the anxiety in the Schizophrenia Severity domain among participants using an independent t-test. Regarding the anxiety post-test sum score, there is a significant difference between interventional group (M=2.30, SD= 0.483) and control group (M=4.70, SD=0.1.059) (t=-6.519, p=<0.001). This means participants who received CBT have shown decreased anxiety sum score in the schizophrenia severity domain compared to those in control groups (Mean difference = 2.40). Table 4 The Effectiveness of CBT treatment on Schizophrenia Severity, and on the anxiety related to schizophrenia severity among participants (n=20) n Mean SD Statistical values Men Different P-value Pre-test schizophrenia severity Sum Score Interventional group 10 111.20 21.698 t=-.519 df=18 4.20 .610 Control group 10 115.40 13.599 Post-test schizophrenia severity Sum Score Interventional group 10 84.10 24.587 t=-3.807 df=18 34.10 <.001* Control group 10 118.20 14.061 Post-test anxiety Sum Score Interventional group 10 2.30 .483 t=-6.519 df=18 2.40 <.001* Control group 10 4.70 1.059 Independent t-test, Min score 30, Max score 210, higher mean score means higher schizophrenia severity *Significant at p=<0.05 38 Figure 3 The Effectiveness of CBT treatment on schizophrenia severity among participants (n=20) 3.6 Factors that Affect Participants' Outcome on Auditory Hallucinations, snoiDuleD and Schizophrenia Severity (Post-test Sum Scores) Independent t-test and One-Way ANOVA were conducted to assess the factors that affect the participant‘s outcome on auditory hallucinations, snofduled, and schizophrenia dngneues (post-tests sum scores). Regarding Auditory Hallucination post-test sum score There are no significant differences were found in all demographic characteristics of the participants (p=>0.05). Regarding Delusion post-test sum score There are no significant differences were found in all demographic characteristics of the participants (p=>0.05) in terms of delusion post-tests sum score. That‘s means participants have same outcome toward delusion. 111.2 115.4 84.1 118.2 Interventional group Control group Interventional group Control group Pre-test schizophrenia severity Sum Score Post-test schizophrenia severity Sum Score The Effectiveness of CBT treatment on Schizophrenia Severity among participants 39 Regarding Schizophrenia severity post-test sum score There are no significant differences were found in all demographic characteristics of the participants (p=>0.05) in terms of schizophrenia severity post-tests sum score. That‘s means participants have same outcome toward Schizophrenia severity. 40 Chapter Four Discussions and Conclusions 4.1 Discussion The goal of this chapter is to compare and contrast the findings presented in Chapter One with existing literature. Hypothesis 1: Using CBTp is effective in treating hallucinations and delusions among patients with schizophrenia at the level of 0.05 The analysis conducted after the test on auditory hallucinations and delusions revealed a notable difference between the intervention group and the control group (p<0.05). This demonstrates that individuals who received CBT showed a decrease in auditory hallucinations, delusions, and overall scores of schizophrenia severity in comparison to participants in the control group. Various studies from around the globe corroborate our findings. Cognitive Behavioral Therapy models tailored for psychosis symptoms (CBTp) have been developed across a broad spectrum of mental health conditions, including schizophrenia. These models have been recommended as beneficial supplementary treatments alongside medication for individuals with schizophrenia, as outlined in numerous studies (Guaiana et al., 2022). Moreover, a review aimed at evaluating the use of CBT as an additional treatment for treatment-resistant schizophrenia (TRS) across different research populations discovered that, out of eight studies meeting the inclusion criteria, five demonstrated statistically significant efficacy of CBT in mitigating the positive psychotic symptoms associated with TRS (Ryan et al., 2022). Additionally, a controlled trial that applied CBT to address insomnia in a large cohort of over 3000 university students also led to a reduction in the manifestation of paranoid delusions and hallucinations among those participants whose insomnia improved (Freeman et al., 2017). Additionally, a randomized controlled trial conducted in Mid-Norway, encompassing both outpatient and inpatient mental health clinics and centering on CBT for psychotic symptoms, revealed that 20 sessions of CBT were more effective than waiting list controls. This was evident in the improved overall scores on the Brief Psychiatric Rating Scale (BPRS), the delusion scale of the Psychotic Symptom Rating Scales 41 (PSYRATS), and the Global Assessment of Functioning (GAF) symptom score following treatment. The findings of this study underscore that CBT, even when delivered by non-expert practitioners in standard clinical settings, can result in enhancements in positive psychotic symptoms (Kråkvik et al., 2013). Additionally, a meta-analysis indicated that CBT for psychosis (CBTp) might offer modest improvements for positive symptoms that are resistant to clozapine treatment. Given the minimal risks associated with CBTp and the scarce alternatives for individuals with clozapine-resistant schizophrenia, this method warrants consideration for this demographic (Todorovic et al., 2020). Moreover, research into the development of new CBT techniques utilizing computerized programs has shown significant reductions in the frequency and intensity of auditory hallucinations, as well as their perceived power and malevolence. Remarkably, some participants reported a complete cessation of these voices following just a few therapy sessions (Leff et al., 2014). Conversely, an assessor-blinded, randomized controlled trial in the UK yielded results that diverged from our study. It found that schizophrenia patients who either could not tolerate clozapine or did not respond to the medication were randomly assigned to either CBT with standard treatment or standard treatment alone. At the 21-month follow-up, measured by the PANSS, CBT did not demonstrate a lasting impact on overall schizophrenia symptoms compared to standard treatment. Nonetheless, CBT did achieve statistically significant, albeit not clinically significant, improvements in total symptoms by the end of the treatment period (Morrison ClinPsyD et al., 2018). This study contrasts with our findings, possibly due to our inability to conduct a 21- month follow-up; hence, our results are based on assessments made at the conclusion of the CBT sessions. In summary, our research supports the effectiveness of CBT in treating delusions and hallucinations within our study population, despite some studies reporting contrary findings. 42 Hypothesis 2: There is a relationship between the type of treatment and levels of anxiety related to hallucinations and delusions among patients with schizophrenia at the level of 0.05 In our study, we observed that participants who underwent CBT experienced reductions in both the amount and intensity of distress and anxiety compared to the control group. This aligns with the findings of other research, leading us to conclude that CBT for psychosis (CBTp) is effective in diminishing distress and anxiety across both delusions and hallucinations domains. The following studies have reported similar outcomes. Freeman utilized CBT focused on worry reduction for patients with persecutory delusions, noting that this approach led to decreases in persecutory delusions. The study highlighted worry and anxiety as potential triggers for delusions, suggesting that interventions targeting worry could be advantageous in psychosis treatment (Freeman et al., 2015). Another study highlighted that neural markers of anxiety change early in the course of CBT, suggesting that these early neural adjustments could influence the clinical benefits of treatment. It was found that a single CBT session could rapidly alter behavioral markers of threat vigilance, which in turn predict symptom recovery within a one-month follow-up period (Reinecke et al., 2018). Moreover, studies evaluating the effectiveness of CBT administered remotely versus traditional in-person CBT and non-CBT control conditions found that remote CBT was superior in managing symptoms of OCD, depression, and anxiety (Salazar de Pablo et al., 2023). This demonstrates that remote CBT using online sessions is a viable option for broadening the availability of treatment as the technology is evolving these days and people have increasing accessibility to audio and video applications through their phones especially in the last few years where covid-19 obstructed free movement of people. Furthermore, a systematic review and meta-analysis examining CBT's impact on anxiety-related psychotic symptoms found a medium, significant effect for post- 43 treatment data, both controlled and uncontrolled, and a small, significant effect for controlled between-group data (Heavens et al., 2019). Hypothesis 3: There were statistically significant differences in patients’ uremlvnrnei who received treatment as usual alone and those who received both CBT and treatment as iDiso at the level of 0.05 This study found that participants who received CBT shown decreased in schizophrenia severity sum score ol deens el those in eon oleeelo groups. soud is consistent with the results of the following studies. Initially, a systematic review dedicated to the CBTp in schizophrenia patients demonstrated that CBT is acknowledged as an effective method for tackling psychosis, addressing both positive and negative symptoms. Moreover, CBT has proven to enhance social functioning, positioning it as a broadly endorsed therapy for psychosis (Töre, 2021). Furthermore, a meta-analysis underlined CBTp's efficiency, suggesting that the common constraints of conventional CBTp could be surmounted by employing individual-participant data (IPD). This approach showed CBTp's superior performance in controlling overall psychotic symptoms and general symptoms as assessed by the PANSS, notably influencing treatment results for positive, negative, and general or total psychotic symptoms following treatment (Turner et al., 2020). In addition, a randomized controlled study investigating cognitive-behavioral therapy in early-stage schizophrenia, carried out across 11 mental health facilities in England over 26 months, indicated that a 70-day treatment regime resulted in marked enhancements in total and positive symptom scores on the PANSS compared to conventional care (Lewis et al., 2002). Moreover, a randomized clinical trial in Tayside assessing CBT for medication-resistant psychotic symptoms observed modest treatment effects, but notable improvements in overall symptom severity were recorded with the CBT approach compared to supportive psychotherapy (SPT) or usual care. Furthermore, a randomized clinical trial in Tayside exploring CBT for medication-resistant psychotic symptoms reported modest treatment effects, yet significant improvements in overall symptom severity were observed with the CBT condition compared to supportive psychotherapy (SPT) or treatment as usual (TAU). The study demonstrated that both CBT and SPT, when combined, resulted in a 44 significant reduction in the severity of delusions compared to TAU, underscoring the value of CBT, delivered by clinical nurse specialists, as a beneficial supplement to standard care for individuals with chronic psychosis (Durham et al., 2003). Hypothesis 4: There are no statistically significant differences in the levels of improvement with other independent variables at the level of 0.05 Our study revealed no significant differences in demographic characteristics among participants concerning auditory hallucinations, delusions, and schizophrenia severity scales. All participants originated from similar environments and had comparable ages, with 70% aged between 15-29 years and 30% between 30-40 years, resulting in a homogenous demographic sample. This lack of diversity is reflected in our findings, as I was only able to work in Hebron mantal health clinic due to lack of corporation with other broader mental health facility which is Bethlehem mental health hospital (the only mental health hospital in the west bank) when they refused allowing me to implement my research on their facility even after taking the approval from the Palestinian ministry of health as a result my population were from similar environments with similar social conditions. We identified only one study aligning with our research. This meta-analysis assessed the effectiveness and moderating factors of Cognitive Behavioral Therapy for Psychosis (CBTp) compared to alternative psychological treatments, analyzed 14 qualified randomized controlled trials (RCTs). It determined that factors such as patient demographics and the intensity of psychotic symptoms have minimal influence on the results of psychological treatments for psychosis, including CBTp (Turner et al., 2020). I believe that the reason for this strange results in these studies is due to lack of diversity in the studies populations. Contrastingly, some studies diverged from our results. For instance, a study investigating the impact of the CBT on insight into schizophrenia across different socio- demographics discovered that improvements in insight were significantly lesser in the Black African group compared to the white group (Rathod et al., 2005). Furthermore, research aiming to identify the delivery of the CBTp through an automated method in a big electroni