If you sit in on a Cognitive Behavioural Therapy for psychosis (CBTp) session, you will see a particular diagram drawn on a whiteboard or notepad more often than any other. Three columns, labelled A, B, and C. This is the ABC model — first articulated by the rational-emotive therapist Albert Ellis in the 1950s, refined by Aaron Beck in his cognitive model of depression, and adapted for psychosis by clinicians like David Kingdon and Douglas Turkington in the 1990s. It is the conceptual backbone of CBTp.
The ABC model says that distress (Consequence) does not come directly from events (Activating event) but from the beliefs (Belief) we attach to them — and that working on the belief is often the most powerful way to change the consequence.
What the letters stand for
- A — Activating event: what happened. An external situation (a stranger looked at me) or an internal experience (I heard a voice say my name).
- B — Belief: the meaning the person attached to the event. ("They were one of the people watching me." "The voice is God testing me.")
- C — Consequence: the emotional, physical, and behavioural result. (Fear, racing heart, locking the door, hiding indoors for the rest of the day.)
The therapeutic move is to introduce the idea that A does not directly cause C. There is always a B in between — and the same A can produce very different Cs depending on the B. This sounds simple. In practice it can be transformative.
A worked example
A composite illustration. A patient — call her Ana — describes the following episode:
A: "I was on the bus and a man across the aisle looked at me twice."
B: "He was checking I was the right person to follow. He was working with the people who are tracking me."
C: "My heart started pounding. I got off the bus three stops early. I went home and didn't leave the house for two days."
In a typical session, the therapist would not challenge the central belief. Instead they would draw the ABC diagram, write Ana's account in her own words, and then — with her permission — explore the B in detail.
- "What other reasons might a stranger glance at someone twice on a bus?"
- "If your friend told you the same story, what other interpretations might she consider?"
- "How sure are you of this interpretation, on a scale of 0 to 100?"
- "What would have to happen for you to feel less sure?"
Ana might generate alternative Bs — that the man was bored, was reading a sign behind her, was attracted to her, was distracted. None of these requires her to abandon her primary belief. The work is to widen the field of possibility.
Why this matters for psychosis specifically
For people with psychosis, the As are often unusual or distressing in themselves — a voice, an intrusive thought, a sensation. The natural human reaction is to assign meaning quickly. Voice → "this is a real entity speaking to me." Intrusive thought → "this means something terrible about me." Sensation → "they are doing something to my body."
The B is doing enormous work. The same voice, attributed to a deceased grandparent who is comforting, generates one C. Attributed to a malevolent demon, it generates another. The voice itself has not changed. The model gives patients language for separating the event from the meaning, which is the entry point for everything else CBTp tries to do.
The fourth column: D, for disputation
Some manuals add a fourth column, D, for disputing or examining the belief. Others use a fifth, E, for the new emotional and behavioural effect after the work. In CBTp, this expansion is generally done gently. The therapist does not "dispute" in the sense of arguing the belief away. They support the patient in disputing their own belief in their own way, or in holding the belief alongside alternatives without losing trust in their own perception.
Common pitfalls
- Skipping engagement — using the model before trust is built can feel cold and reductive
- Treating B as wrong — the model is about widening possibility, not declaring a winner
- Forgetting the affect — emotions in C are often the strongest lever, and need to be honoured before the B can be examined
- Forcing alternative Bs the patient does not generate — alternatives that come from the patient hold; alternatives imposed by the therapist do not
Using ABC outside the therapy room
One of the practical strengths of the ABC model is that patients can keep using it on their own. A simple notebook, an app, or a Frida-style daily journal can capture an ABC entry whenever something distressing happens. Over weeks the patient builds a library of their own patterns — the recurring As, the favourite Bs, the predictable Cs. This material is gold for the next session and, eventually, for the patient managing on their own.
Where the model came from
Albert Ellis introduced the ABC framework as part of Rational Emotive Behaviour Therapy in the late 1950s. Aaron Beck independently developed his cognitive therapy with a closely related architecture (situation → automatic thought → emotion → behaviour). When Kingdon and Turkington adapted cognitive therapy for psychosis in the 1990s — work documented in their Cognitive Therapy of Schizophrenia textbook — they kept the ABC structure largely intact, with adjustments to the kinds of beliefs and the slower pacing the population required. The model is now embedded in nearly every CBTp manual and is endorsed in NICE CG178 as part of the recommended approach.
For people doing this work
If you are starting CBTp, expect to see ABC diagrams a lot. They look simple, almost embarrassingly simple. That is part of why they work. The simplicity creates a shared language between you and the therapist that survives session-to-session, and a mental tool you can carry into the rest of your life.
This article is for educational purposes only and is not medical advice, diagnosis, or treatment. Always consult a qualified mental health professional. If you or someone you know is in crisis, call or text 988 in the US, or your local emergency number.