Cognitive Behavior Therapy for Psychosis: Where Have We Been and Where Are We Going?

Abstract

Cognitive behavior therapy for psychosis (CBTp) is an evidence-based treatment primarily designed to target psychotic symptoms such as delusions and hallucinations that persist despite appropriate treatment with antipsychotic medication. Meta-analyses suggest that CBT improves positive symptoms, negative symptoms, and functional outcomes with modest effect sizes compared with active control conditions for individuals with schizophrenia.1–4 CBT is recommended as a standard of care for individuals with schizophrenia in both the Schizophrenia Patient Outcomes Research Team5 and the National Institute for Health and Clinical Excellence6 treatment guidelines in the United States and United Kingdom, respectively. Acceptance of CBTp for the treatment of schizophrenia required substantial evidence of efficacy to contradict the widely held belief that talk therapy was not effective for psychosis patients. Clinical trials published in the 1980s demonstrated that individual psychoanalytically oriented psychotherapy was not helpful and may possibly be harmful for patients with schizophrenia.7,8 These data as well as the dominance of the biomedical model in the United States may have helped to shift the focus of treatment for schizophrenia in the United States away from talking therapies to a primary focus on medication treatment, psychoeducation, and rehabilitation approaches.9 As a result, while the first published case of CBTp was written in the United States by Aaron Beck10 in the 1950s, the evidence base for the efficacy of CBT has primarily come from randomized trials in the United Kingdom. The most recent meta-analysis included 34 studies with 22 studies of individually delivered CBT focused on positive symptoms.1 Despite the number of trials and the evidence supporting CBTp, many questions remain unanswered.11 While CBT has been found to improve several aspects of outcome, more information is needed about the specific techniques or approaches that are most effective in producing change for individuals with particular presentations of the disorder. It is also unclear whether there are individual patient characteristics that predict outcome in CBT. Since its initial introduction, CBT has continued to evolve, incorporating the latest developments in cognitive theory and metacognition. In addition, CBT techniques have been utilized to enhance existing evidence-based treatments such as social skills training. This theme issue presents a series of articles designed to explore the mechanisms of change in specific outcomes during CBT, to broaden our understanding of factors that may predict response to CBT, and to describe some of the important developments in CBTp that may allow us to better individualize treatment. In the first article, Brabban and colleagues examine the predictors of response to brief CBT delivered in the community by psychiatric nurses. By identifying individuals for whom brief forms of CBT are likely to be effective, a triage system utilizing different “doses” of CBT for individuals with different characteristics may be possible. The second article by Tai et al describes the evolution of CBT from primarily behaviorally focused to its current state in which components of many different cognitively based therapies are included in CBTp to address specific illness presentations (eg trauma). The collection of these cognitive techniques is likely to allow more targeted treatment that is better customized for individuals with different problems, personal histories, and views of the world. The third and fourth articles discuss the inclusion of CBT into other evidence-based treatments. The article by Granholm and colleagues describes Cognitive Behavioral Social Skills Training, a group-delivered intervention that is designed to address dysfunctional attitudes such as social disinterest that may be mediators between cognitive impairment and functional outcome. The article reviews the efficacy of CBT delivered in a group format and examines the specific effects on attitudes of social disinterest of CBT vs the nonspecific effects of interaction in a group therapy setting. The final article in the series examines the incorporation of CBT into Cognitive Adaptation Training, a home-delivered treatment using environmental supports such as signs, checklists, and the organization of belongings to cue and sequence adaptive behavior. The combination treatment called multimodal cognitive therapy (Mcog) is designed to bypass formal neurocognitive deficits and to cue and sequence functional behaviors. In addition, Mcog seeks to identify and alter emotional processes, information-processing deficits, and reasoning and appraisal biases that contribute to the formation and maintenance of positive symptoms. In sum, this series of articles addresses predictors of treatment response, mechanisms of change, integration with other treatment modalities, and how CBTp can be adapted to better address individual needs.