Behavioural Therapy For Psychosis Research Articles

A Brief Review of Key Models in Cognitive Behaviour Therapy for Psychosis

Cognitive behavioural therapy (CBT) was originally developed as a comprehensive theory for treating depression. It has, however, since been extensively used to treat a wide range of emotional and mental health problems and is now a plausible treatment of choice for schizophrenia and associated psychotic symptoms. This review highlights the different models of CBT used for treating psychosis. These models have varying background, theory and rationale. Overall, literature shows that there are several models and approaches available but an underlying factor shared by all is the centricity of collaborative empiricism and individual formulation of specific presentations, however this varies across models. These models begin to address the impact of culture on treatment of psychosis. That is, they begin to acknowledge that different cultures may have different interpretations of a psychotic presentation such as delusions. It is imperative that models such as those presented here begin to acknowledge cultural influences and take these into account during their formation. This will have an impact on the way psychosis is treated using CBT. By being receptive to this, it could aid the client-therapist relationship and thus the outcomes of treatment.

Re: Can Cognitive Remediation improve subsequent response to low-intensity Cognitive Behaviour Therapy for Psychosis in people with schizophrenia?

Re: Can Cognitive Remediation improve subsequent response to low-intensity Cognitive Behaviour Therapy for Psychosis in people with schizophrenia?

Effectiveness of Brief Individual Cognitive Behavioral Therapy for auditory hallucinations in a sample of Egyptian patients with schizophrenia

BackgroundAuditory hallucination is one of the most common symptoms in schizophrenia. The frequency of the auditory hallucinations and ensuing distress make the individual believe that these voices are not able to be controlled and to be coped with.AimTesting the effectiveness of brief cognitive behavioral therapy for psychosis (CBTp) for auditory hallucinations, using it in modifying the beliefs about the voices and improving symptom severity and overall functioning.MethodsForty participants with schizophrenia were randomized into intervention and control groups. Intervention group were 20 patients who received 8 individual sessions of CBTp plus Treatment As Usual (TAU) over 8 weeks and the control group were the other 20 patients who received TAU only. The Positive and Negative Syndrome Scale (PANSS), the Arabic version of Beliefs About Voices Questionnaire (BAVQ) and the General Assessment of Functioning scale (GAF) were assessed at baseline and at the end of the study.ResultsIntervention group showed a statistically significant increase in GAF (P = 0.012), a statistically significant reduction regarding the Positive (P < 0.001), Negative (P = 0.008), General (P < 00.001) and total (P ≤ 00.001) sub-scales of PANSS. Regarding BAVQ, Intervention group showed a statistically significant reduction in Malevolence (P = 0.008), Engagement (P = 0.001); and showed a statistically significant increase in Resistance (P = 0.049) compared to control.ConclusionsBrief cognitive behavioral therapy for auditory hallucinations can improve severity of schizophrenia, increase the level of functioning and improve the beliefs about the voices.Disclosure of interestThe authors have not supplied their declaration of competing interest.

A medical psychotherapist’s journey learning Cognitive Behaviour Therapy for Psychosis

A medical therapist’s journey learning to use Cognitive Behaviour Therapy for Psychosis is described. This experience provided a potential pathway to improved engagement through the provision of optimism, hope and respect for the others’ personhood. However, risks associated with such therapeutic engagement and the capacity of mental health services to support this work need to be considered. The impacts of this training on the clinical practice of the author are described with emphasis on the behaviour and attitudes of the therapist. Training in CBTp was a highly valued experience, and opportunities to complete this should be made routinely available to trainee psychiatrists.

Individual factors predicted to influence outcome in group CBT for psychosis (CBTp) and related therapies.

Cognitive behavioral therapy for psychosis (CBTp) and CBT based interventions, such as Metacognitive Training for psychosis (MCT), have been found to be effective in symptom reduction, relapse prevention and, increased quality of life (Moritz et al., 2014). A number of reviews (Tarrier et al., 2002) and meta-analyses (Wykes et al., 2008) have confirmed that group CBT (including MCT) is effective for psychosis (Lecomte et al., 2012), but there is significant heterogeneity in outcome (Zimmermann et al., 2005), with some patients able to gain significantly from participating in psychotherapy, whereas others gain minimally. Given the limited resources available for psychotherapy in psychosis, an important endeavor is the identification of factors that may optimize the allocation of those resources (Zimmermann et al., 2005; Freeman, 2011). While there is a growing body of literature on factors influencing outcome in psychotherapy (Luborsky et al., 1971), that has examined patient, therapist and treatment factors, there is a relative paucity of research focussed on outcomes in group psychotherapy for psychosis. In this opinion paper, we highlight a number of patient factors (including aspects of symptomatology, cognition and personality) that might play a role in outcome in group psychotherapy for psychosis. These factors are based on research of psychotherapeutic outcomes (in psychosis and other disorders), with additional observations based on our clinical experience. Symptom related factors Paranoia, lack of insight and their effects on treatment alliance There is a large body of literature that has focussed on the non-specific factors associated with outcomes in other psychiatric disorders, and synthesizing it is beyond the scope of the current paper. The bulk of this research has looked at the importance of the therapeutic alliance (Martin et al., 2000), as perceived by the therapist and the client, and suggests that client perceptions of alliance are better predictors of outcome (Krupnick et al., 1996). Crucial to the alliance is the client's belief that they can trust the therapist, and feel understood by them (Frank and Gunderson, 1990). In the context of groups, an additional factor is the ability to trust the other group members. These critical components are negatively impacted by paranoia, and therapists working with clients with psychosis need to grapple with therapeutic ruptures and to avoid being integrated into the client's delusional framework. CBT based interventions also require ways to discuss specifics of the delusional beliefs (such as the nature of evidence used to maintain the belief), as well as finding shared goals, even when clients have poor insight into their symptoms. This can be a delicate process, with a lot of potential for damaging the alliance. Goldsmith et al. (2015) found that the duration of therapy was associated with symptomatic improvement in those with good treatment alliance, but was actually detrimental for those clients with poor treatment alliance. Skilled therapists find creative solutions to negotiate these processes. For some clients, particularly those with paranoia, relatively poor insight and an unwillingness to discuss the specifics of their delusional system, a more indirect approach (such as the one provided by MCT) (Kumar et al., 2015) may provide a more fruitful avenue of engagement (Menon et al., 2015). This is because MCT involves a group discussion of cognitive biases commonly associated with psychosis, and opportunities to examine the impacts of these biases in session, using non-delusion specific, and thus less threatening, material (Woodward et al., 2014).

Can cognitive behaviour therapy beneficially influence arousal mechanisms in psychosis?

Cognitive behavioural therapy for psychosis (CBTp) is an approved adjunct therapy for patients with psychotic disorders; however, we do not fully understand the neurobiological effects that this therapy may exert. Arousal, as measured by electroencephalography (EEG), provides a useful electrophysiological marker for assessing psychotic disorders. EEG studies may therefore serve as a useful measure for assessing the underlying effects of CBTp in psychotic disorders.

Paranoia in the Therapeutic Relationship in Cognitive Behavioural Therapy for Psychosis

This study explored therapists' and clients' experiences of paranoia about the therapist in cognitive behaviour therapy. Ten therapists and eight clients engaged in cognitive behaviour therapy for psychosis were interviewed using a semi-structured interview. Data were analyzed using thematic analysis. Clients reported experiencing paranoia about their therapist, both within and between therapy sessions. Therapists' accounts highlighted a number of dilemmas that can arise in responding to clients' paranoia about them. The findings highlight helpful ways of working with clients when they become paranoid about their therapist, and emphasize the importance of developing a therapeutic relationship that is radically collaborative, supporting a person-based approach to distressing psychotic experience.

EPA-0259 – Reducing the frequency and severity of voices: the avatar clinical trial

Around a quarter of people suffering from psychotic conditions, like schizophrenia, continue to experience auditory hallucinations despite adequate drug treatment. In addition to medication, some help is also provided by psychological interventions, particularly cognitive behavioural therapy for psychosis (CBTp). AVATAR therapy is based on computer technology which enables each patient to create an avatar of the entity (human or non-human) that they believe is talking to them. The therapist promotes a dialogue between the patient and the avatar in which the avatar progressively comes under the patient's control. These sessions are audio recorded and provided to the patient on an MP3 player for continued use at home. In an initial pilot study, a maximum of 7 sessions lasting 30 minutes resulted in highly significant reductions in the patients’ hallucinations and the associated distress, enhancing the quality of their life (Leff et al., 2013). Our objective is to replicate the findings of this pilot study of the AVATAR therapy. We will carry out a randomised controlled evaluation of computer assisted voice therapy compared to supportive counselling to determine preliminary estimates of both effectiveness and cost-effectiveness. The study aims to recruit 142 people who have suffered from auditory hallucinations for at least 12 months despite taking medication regularly. Participants will complete a number of selfcompleted and interview based measures (on four assessment points: pre-treatment, post treatment, and then at 12 and 24 weeks follow-up) to assess the impact of interventions on outcomes and to explore potential mediators and modifiers of therapy.

Cognitive behavioural therapy for psychosis and anxiety

This article discusses the effectiveness of a cognitive behavioural therapy (CBT) group for clients with a first episode of psychosis, who were also experiencing comorbid symptoms of anxiety. Clients of 18-35 years of age who reported anxiety symptoms, either as a direct or indirect result of psychotic symptoms, were invited to attend a 12-week CBT-based group. The effectiveness of the intervention was evaluated at screening and 3-month follow-up with the Depression, Anxiety and Stress Scale (DASS-21) (Lovibond and Lovibond, 2004). The results showed a statistically significant improvement in symptoms (depression, p=0.06; anxiety, p=0.05; stress, p=.014), sustainable at 3-month follow-up. The authors concluded that a CBT group for people with a first episode of psychosis that focuses on the management of anxiety can be an effective and viable means of reducing levels of anxiety and associated stress and depression. This model is recommended for use by community mental health teams.

Associations between therapy skills and patient experiences of change processes in cognitive behavioral therapy for psychosis

Despite the promising findings in relation to the efficacy of cognitive behavioral therapy for psychosis (CBTp), little attention has been paid to the therapy skills necessary to deliver CBTp and to the influence of such skills on processes underlying therapeutic change. Our study investigated the associations between general and technical therapy skills and patient experiences of change processes in CBTp. The study sample consisted of 79 patients with psychotic disorders who had undergone CBTp. We randomly selected one tape-recorded therapy session from each of the cases. General and technical therapy skills were assessed by the Cognitive Therapy Scale for Psychosis. The Bern Post Session Report for Patients was applied to measure patient experiences of general change processes in the sense of Grawe's psychological therapy. General skills, such as feedback and understanding, explained 23% of the variance of patients' self-esteem experience, but up to 10% of the variance of mastery, clarification, and contentment experiences. The technical skill of guided discovery consistently showed negative associations with patients' alliance, contentment, and control experiences. The study points to the importance of general therapy skills for patient experiences of change processes in CBTp. Some technical skills, however, could detrimentally affect the therapeutic relationship.

Advances in Cognitive Behavior Therapy for Psychosis

This article discusses several models of Psychosis, research on Cognitive Behavior Therapy for Psychosis (CBTp) and recent developments and new directions in the theory and practice of CBTp. Throughout the article we focus on the evolution of the field of CBTp as well as issues and opportunities for the field. We have highlighted the evolution of a more humanistic and strengths-based approach to recovery in psychosis, which focuses to a greater extent on personal values and goals rather than symptoms, as compared to earlier CBT models for psychosis. We have also consolidated information related to trends and innovations in CBTp. In the spirit of clinical utility, we have emphasized and referenced clinical resources and practical materials on CBTp interventions. Finally, we highlight the need for further research, enhanced consumer involvement, and increased access and resources for those with lived experience of psychosis.

Assessing Therapist Adherence to Recovery-Focused Cognitive Behavioural Therapy for Psychosis Delivered by Telephone with Support from a Self-Help Guide: Psychometric Evaluations of a New Fidelity Scale

Recent research has highlighted the importance of psychological interventions such as cognitive behavioural therapy (CBT) in improving outcomes and promoting recovery for people with experience of psychosis, although a lack of trained therapists means that availability of face-to-face CBT is low. Alternative modes of delivering CBT are being explored, such as telephone and self-help methods, although research to date on whether they can be implemented effectively is limited. The aims of the present study were to describe and evaluate a new therapy fidelity scale (ROSTA; Recovery Oriented Self-help and Telephone therapy Adherence). This scale was developed to assess fidelity to cognitive behaviour therapy for psychosis (CBTp) focused on improving recovery, with optional subscales for delivery over the telephone and alongside a self-help guide. Experienced CBT therapists rated recorded therapy sessions using the ROSTA scale. The scores were used to assess internal consistency and inter-rater reliability, before being compared to scores from an independent expert rater using an alternative fidelity scale for cognitive therapy in psychosis (the CTS-Psy), to investigate concurrent validity. The ROSTA scale demonstrated excellent internal consistency, inter-rater reliability and validity when evaluated as a whole, although findings were mixed in terms of the individual subscales and items. The ROSTA scale is, on the whole, a reliable and valid tool, which may be useful in training and supervision, a utility that would be further emphasized if the therapeutic intervention it assesses is deemed to be efficacious based on future work.

Cognitive and behavioural therapies for psychosis

Abstract Cognitive Behavioural Therapy for psychosis (CBTp) is a recommended treatment in several international guidelines for schizophrenia and psychosis. CBTp is an adaptation of traditional cognitive behavioural therapy for emotional disorders, modified for the specific needs of people with psychotic symptoms. This chapter will give a practical introduction on the key elements and principles of CBTp, illustrative examples of its use, and a brief summary of the current evidence base, including discussion of efficacy, effectiveness, effect size, and treatment targets. It will highlight key issues, including the importance of fidelity to treatment protocols, agreement on shared goals between client and therapist, and a normalising approach to psychotic experiences. Challenges to implementing CBTp, at scale, and in routine clinical practice will also be discussed.

Thérapie comportementale et cognitive des troubles schizophréniques : actualités et perspectives

Cognitive and Behavioral Therapy for Psychosis is really booming for thirty years. Many skills have demonstrated a good effectiveness to treat medication-resistant symptoms. This paper goals are to focus on the main skills currently used to treat positive or negative symptoms of psychosis, to present perspectives for the young patients, and to change minds about the future of these patients who can claim today recovery and rehabilitation.

Does Symptom Type Moderate the Relationship Between Insight and Outcome in Cognitive Behavioral Therapy for Psychosis? A Preliminary Investigation

Insight has emerged as a potential predictor variable in cognitive behavioral therapy for psychosis (CBTp). However, previous research has produced mixed results. The present study aimed to clarify whether symptom type is a moderating variable. A group of psychotic patients (n = 44) were assessed through pre- and post-treatment in a CBTp specialty track in a partial hospital-based program in the USA. The Insight Scale was used to measure insight, and psychotic symptomatology was assessed using the Mini-International Neuropsychiatric Interview and the Behavior and Symptom Identification Scale. Patients showed a significant decrease in psychotic symptom scores over the course of treatment [t(43) = 3.59, p < .001, Cohen's d = .64]. Furthermore, illness awareness was specifically associated with a decrease in psychotic symptoms for patients who endorsed visual hallucinations (r = − .68, p < .01), auditory hallucinations (r = − .49, p = .01), and/or ideas of reference (r = − .66, p < .01). Insight did not confer additional benefit for patients with paranoid delusions, mind reading, or thought insertion symptoms. These results are discussed in relation to treatment implications within the current US health care delivery system.

Cognitive Behavioural Therapy for psychosis

SummaryCognitive Behavioural Therapy for psychosis (CBTp), with its theoretical underpinning derived from cognitive models of psychosis, is described. The therapeutic approach is elucidated, in terms of goals, techniques, content and style. Adjustments of the therapy to address the particular problems of psychosis, including building a therapeutic relationship and matching cognitive capacities, are highlighted. The extensive evidence for the effectiveness of CBTp is reviewed and methodological issues in trials noted. The evidence shows that CBTp has small to medium effects on a range of outcomes, including symptoms, affect and functioning, and that the evidence is most consistent for improvements in people with persistent positive symptoms. New developments in CBTp are described, and the promise of developing focused treatments targeting specific psychological processes, such as reasoning or emotional processes, hypothesized as causal mechanisms of distressing symptom persistence. Finally, to support implementation of CBTp in practice, it is concluded that there is a need for dissemination programs, addressing staff attitudes and skills and wider system changes.

FC19-03 - Advances in cognitive behaviour therapy for psychosis

IntroductionCBT for psychosis has been developed over the past two decades and is now recommended by most clinical guidelines for schizophrenia internationally.Aims &amp; objectivesTo provide an up-date on advances and controversies in CBT for psychosis.MethodEvidence from recent meta-analyses (including Lynch et al, 2010) and randomised controlled trials will be reviewed. These have generally demonstrated effectiveness in early and treatment-resistant schizophrenia of CBT, and other specific indications, e.g. co-morbid substance misuse, aggressive behaviour, command hallucinations. Treatment is based on engaging the patient in a therapeutic relationship, developing an agreed formulation and then the use of a range of techniques for hallucinations, delusions and negative symptoms.ResultsEvidence of effectiveness in treatment-resistant psychosis remains strong but some areas for intervention remain under-researched. A series of studies are on-going which will provide more information about effective ways of working.ConclusionsCBT is a very important but under-used intervention which can make clinically significant differences to patient's lives.

Feasibility of Implementing Cognitive Behavioral Therapy for Psychosis on Assertive Community Treatment Teams: A Controlled Pilot Study

Cognitive behavioral therapy for psychosis (CBTp) has been shown to reduce symptoms of schizophrenia, but implementation of CBTp interventions in community settings in the U.S. has not been studied. This study examined whether community case managers can effectively deliver manualized CBTp to clients with psychosis. Community case managers from assertive community treatment teams received a one-day training workshop and bi-weekly group supervision and delivered CBTp to clients with psychotic disorders in their caseload for 12 weeks. On average, only half (6 of 12) the manualized sessions were delivered. Patients who received more sessions learned more skills and had better outcomes, and greater skill learning was correlated with greater improvement in several outcomes. Case managers, on average, delivered CBTp with adequate fidelity CBTp can be effectively delivered by front-line mental health workers, but implementation barriers hindered delivery of an adequate dosage of therapy.

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

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.

Cognitive Behaviour Therapy for Psychosis: Current Evidence and Future Directions

AbstractThe past decade has seen considerable growth in the evidence base of cognitive behavioural therapy for psychosis. Consistent reports of moderate effect sizes have led to such interventions being recommended as part of routine clinical practice. Most of this evidence is based on a generic form of CBT for psychosis applied to a heterogeneous group. An increase in the effectiveness of cognitive behavioural interventions may require new protocols. Such therapeutic developments should be based on the theoretical understanding of the psychological processes associated with specific forms of psychotic presentation. The current evidence base of CBT for psychosis is reviewed, and barriers that have held back the development of this research are discussed.