My name is Gary Cusick, PhD. I am a licensed clinical psychologist in Louisville, Kentucky who has worked with persons with an impairment of vision for 18 years. Roughly one in three of my clients reported having simple or complex Charles Bonnet (CBS) hallucinations or images.
Important points include:
CBS occurs in persons with a visual loss in at least one eye from any cause.
It is not related to dementia or psychosis.
While most persons known to have CBS are elderly, children can also have it.
The International Classifications of Diseases for Mortality and Morbidity Statistic, 11th Revision, V2022-02 has defined CBS as Visual Release Hallucinations (9D56). That definition refers to CBS as temporary, but I have worked with persons who have had CBS for more than 20 years.
Charles Bonnet (1720-1792)
Bonnet practiced law but was also a naturalist. He published a paper in 1760, describing his blind but otherwise mentally sound grandfather’s complex hallucinations caused by cataracts.
Charles Bonnet images do not exist in the real world
I would strongly advise against believing the images have some purpose in the world or in your life. They use the same visual brain systems that one used before sight loss so they may appear to be outside of the self. Caregivers will never be able to see them because the images are coming solely from your brain’s visual systems.
There is no way to act on the images. If trying to touch them gives you comfort however, give it a try. Some people will use flashlights, spray bottles, or throw things at them. The image cannot hear you even if they appear to be responding to something you’ve said. Some people will yell at them or politely ask them to leave. Doing these things may reinforce that they are not real. Do not do anything that can hurt those around you.
Hallucinatory Experience in Sighted Persons.
Anyone can experience a hallucination at the moment of falling asleep or waking up. These are hypnagogic and hypnopompic hallucinations respectively. These happen to sighted people as well. Persons participating in a sensory deprivation experiment or situation may experience visual hallucinations. Several medications may cause visual manifestations. Loneliness and isolation are sufficient to cause hallucinations
Amygdala Hijack
One cause of the anxiety attending CBS, is that it comes on in a flash, often startling the person. Part of your brain called the amygdala will actually perceive the image before it comes into conscious awareness. The amygdala’s job is to ensure that the person's physiological state is ready for fight or flight. Your body would respond to this, by raising your heart rate, dumping adrenaline into the bloodstream, and causing your palms to become sweaty. A person in this position would react with some fear to any type of image including those that are not fear inducing at other times.
The phenomenon helps to explain why a person may be unable to use reason to assure themselves that the images are not real. I have heard people say that “in the moment” it is difficult to deny the reality of an image. Given the opportunity to consider the likelihood of 30 people appearing in the bathroom, the person may reason that they are not real.
Dreams and Charles Bonnet
As said before, the CBS images are created from visual memories. Something you’ve seen, even if not consciously remembered, can become elements of a dream. Locations, objects, and people in dreams come from visual memories. Experiencing a dream, one believes that what one sees is real. Dreams also include sounds.
CBS is not a dream. Your brain is in a different state when dreaming. Visual memories are used to produce the CBS images. There is no sound related to CBS images. As in a dream, what one sees experiencing a CBS image is not real, not matter how real it seems.
Time of day
The medical literature suggests that CBS will be more frequent in the evening. Although this may raise a comparison with sundowner’s syndrome experienced by persons with dementia. Rather, it is just the dimming of light in the evening that may bring on a CBS image. When it is getting dark, anyone may misinterpret what they are seeing.
While there are those who see more images in evening hours, a CBS image can appear at any time of day. Upon waking is a frequent time that CBS images are seen.
12-Session CBT Manual for Charles Bonnet Syndrome (CBS)
A structured cognitive-behavioral treatment program for individuals experiencing visual hallucinations due to vision loss.
TABLE OF CONTENTS
Program Overview & Rationale
Psychoeducation Handouts
Therapist Session Structure Template
Session-by-Session Therapist Guides (1–12)
Worksheets & Handouts
Relapse Prevention & Long-Term Management
Treatment Summary Sheet
1. PROGRAM OVERVIEW & RATIONALE
Target Population
Individuals with significant vision loss who experience complex visual hallucinations consistent with Charles Bonnet Syndrome (CBS) and who are distressed, confused, or impaired by them.
Core Goals
Reduce distress from hallucinations
Improve understanding of CBS
Modify misinterpretations (e.g., “I’m going crazy,” “This is psychosis”)
Build cognitive and behavioral coping strategies
Increase control, predictability, and confidence
Prevent escalation of anxiety, isolation, or sleep disruption
Primary Techniques
Psychoeducation specific to CBS
Cognitive restructuring targeted at catastrophic interpretations
Attention redirection techniques
“Hallucination grounding” behavioral skills
Trigger awareness training
Behavioral activation (to counter isolation & sensory deprivation)
Relapse-prevention strategies
2. PSYCHOEDUCATION HANDOUTS (PATIENT-FACING)
(Low-ink printing style.)
What is Charles Bonnet Syndrome?
CBS occurs when the brain generates visual images in response to vision loss.
It is not psychosis, not dementia, and not a sign of mental illness.
The brain “fills in” missing visual information with stored patterns.
Common Hallucinations in CBS
People, faces, animals
Patterns, grids, geometric forms
Landscapes
Miniature figures
Repeating images
Distorted scenes
Lilliputian hallucinations
Why It Happens
Reduced visual input → reduced feedback to visual cortex → spontaneous activity
Similar to phantom limb pain (“phantom vision”)
Typical Triggers
Low lighting
Fatigue
Social isolation
Sensory monotony
Lack of cognitive stimulation
Stress or anxiety
What Makes It Worse?
Panic or catastrophizing
Avoidance behavior
Focusing too intently on hallucinations
What Helps?
Brightening the environment
Engaging multiple senses
Moving eyes or head
Blinking repeatedly
Cognitive reframing
Staying socially connected
3. STANDARD THERAPY SESSION STRUCTURE
Check-in (mood, hallucination frequency/severity)
Review homework
Set agenda collaboratively
Focus on session skill/lesson
Practice skill
Summarize & troubleshoot
Assign homework
4. SESSION-BY-SESSION CBT PLAN (CBS-SPECIFIC)
SESSION 1 — Assessment, Engagement & CBS Psychoeducation
Goals
Establish rapport
Assess visual hallucinations, triggers, patient interpretation
Provide introductory psychoeducation
Reduce fear (“I’m losing my mind”)
Encourage tracking
Core Messages
CBS is common, benign, and neurologically normal after vision loss.
You are not going crazy.
Homework
Track hallucinations (time, description, lighting, distress)
Read psychoeducation sheet
SESSION 2 — Understanding Hallucinations as Sensory Misperceptions
Goals
Provide deeper neuropsychological model
Separate hallucinations from meaning
Reduce catastrophic interpretations
Skills
Event → Interpretation → Emotion model
Re-label hallucinations as “brain-generated visual noise”
Homework
Continue tracking
Identify “trigger situations”
SESSION 3 — Identifying Cognitive Distortions (CBS-Focused)
Common distortions in CBS:
Catastrophizing (“This means brain damage”)
Mind-reading (“People think I’m crazy”)
Overgeneralization (“It’s getting worse forever”)
Emotional reasoning (“It feels scary so it must be dangerous”)
Homework
Begin 1–2 thought records based on CBS episodes
SESSION 4 — Cognitive Restructuring for Hallucination-Related Fear
Goals
Challenge misinterpretations
Create balanced interpretations to replace catastrophic ones
Example Balanced Thought
“My brain is producing images because my eyes can’t. This is normal in CBS.”
Homework
Complete 2–3 full thought records
Collect evidence for/against worry beliefs
SESSION 5 — Behavioral Activation to Reduce Isolation & Sensory Deprivation
Rationale
Isolation, darkness, and inactivity increase CBS hallucinations.
Activities
Build personalized activity plan
Identify social contact options
Increase sensory richness (audio, tactile, mobility)
Homework
Use weekly activity schedule
Rate distress before & after activities
SESSION 6 — Attention Redirection & Grounding Techniques
Teach immediate “hallucination-interruption” strategies:
Rapid Techniques
Blink repeatedly
Move eyes left-right-left
Change lighting
Stand up / walk
Touch surfaces with varying textures
Name 5 things you hear
Hum or speak aloud
Shake head (“reset” signal)
Homework
Use 2–3 techniques during hallucinations
Log effectiveness
SESSION 7 — Behavioral Experiments: Testing Predictions
Examples:
“If I do X, will hallucination change?”
“Does brighter light decrease intensity?”
“If I turn my head, do images stay in place?”
This helps differentiate CBS from psychosis and builds mastery.
Homework
Conduct at least one behavioral experiment
Log outcome
SESSION 8 — Managing Triggers: Lighting, Fatigue, Stress, Loneliness
Skills:
Environmental modifications
Sleep hygiene
Structured routines
Stress management
Social reconnection plan
Homework
Create a “CBS Trigger Plan”
Implement one environmental change
SESSION 9 — Emotion Regulation & Anxiety Management
Hallucination distress often worsens because of anxiety.
Skills
Diaphragmatic breathing
Muscle relaxation
Grounding statements
Worry-time scheduling
Homework
Practice relaxation exercises daily
Use grounding statements during episodes
SESSION 10 — Long-Term Coping Skills & Autonomy
Goals
Prepare client to self-manage CBS
Integrate cognitive + behavioral skills
Identify early relapse signs (e.g., increased isolation, low lighting)
Homework
Draft relapse-prevention plan
SESSION 11 — Relapse Prevention II & Crisis Planning
Work
Refine relapse plan
Role-play early intervention responses
Identify supports (family, clinicians, low-vision services)
Homework
Finalize written plan
Identify top 3 “go-to” coping skills
SESSION 12 — Termination, Future Planning & Skills Review
Goals
Review treatment gains
Reinforce independence
Celebrate mastery
Set optional booster sessions
Client Takeaway
Individualized coping plan
Personalized CBS understanding
Early-warning checklist
5. WORKSHEETS & HANDOUTS (PRINT-READY)
A. CBS-Specific Thought Record
Event
Hallucination description
Initial interpretation
Emotion (0–100)
Alternative explanation (CBS-normalizing)
Balanced thought
Emotion (re-rate)
B. Attention Redirection Skills Sheet
Blinking
Eye shifting
Head turning
Tactile grounding
Auditory grounding
Lighting changes
C. Activity Scheduling (CBS Version)
Columns include:
Lighting conditions
Social interaction
Sensory richness rating
D. Behavioral Experiment Form
Prediction
Experiment
Outcome
Learning
Distress before/after
E. Relapse Prevention Plan
Early warning signs
Trigger situations
Coping actions
Lighting plan
Support people
When to contact clinician
6. RELAPSE PREVENTION & MAINTENANCE
Maintain adequate lighting in key rooms
Use grounding techniques early
Keep regular social engagement
Monitor sleep and fatigue
Revisit cognitive reframing statements
Keep low-vision services involved
7. END-OF-TREATMENT SUMMARY
Skills mastered
Triggers identified
Effective coping strategies
Long-term management plan
Personal statement of mastery