Academic journal article Journal of Cognitive Psychotherapy

The Relationship between Cognitive Behavioral Therapy Maintenance Processes, Emotional Distress, and Positive Psychotic Symptoms: Evidence That CBT Is "Not a Quasi-Neuroleptic"

Academic journal article Journal of Cognitive Psychotherapy

The Relationship between Cognitive Behavioral Therapy Maintenance Processes, Emotional Distress, and Positive Psychotic Symptoms: Evidence That CBT Is "Not a Quasi-Neuroleptic"

Article excerpt

Cognitive behavioral therapy for psychosis (CBTp) has enjoyed a steep rise in popularity over the past 15 years; however, recent systematic reviews and meta-analyses have concluded that CBTp has only modest effects on psychotic syndrome outcomes and that empirical evidence of its superiority over other psychosocial treatments is poor. And although it has been argued by some prominent authors that CBTp is not designed to alleviate the "psychotic syndrome," there is little empirical evidence linking CBTp change mechanisms with syndrome versus single-symptom outcome measures. This study investigated the relationship between CBTp change processes, beliefs about voices, and thought control strategies, with a range of outcome measures including global positive psychotic symptoms in a sample of 40 voice hearers with established diagnosis of psychotic disorder. Consistent with the assertions of Birchwood and Trower (2006), global positive symptoms were found to be generally poorly related to CBTp change processes. Conversely, these CBTp change processes were found to be generally strongly related to measures of emotional distress and some measures of single psychotic symptoms. The implications for past and future CBTp treatment outcome studies are discussed.

Keywords: cognitive behavioral therapy; psychosis; CBT; schizophrenia; CBT for psychosis

Despite cognitive behavioral therapy for psychosis (CBTp) enjoying specific endorsement by the United Kingdom's National Health Service as an evidence-based psychosocial treatment for schizophrenia for approximately a decade (National Institute for Clinical Excellence, 2002), a Cochrane Review of CBTp versus other psychosocial treatments for schizophrenia recently concluded "Trial-based evidence suggests no clear and convincing advantage for cognitive behavioral therapy (CBT) over other-and sometime much less sophisticated-therapies for people with schizophrenia" (Jones, Hacker, Meaden, Cormac, & Irving., 2012, p. 2).

The Cochrane review followed the earlier publication of a comprehensive meta-analysis of 32 CBTp studies by Wykes, Steel, Everitt, and Tarrier in 2008. This meta-analytic study reported finding a modest effect size for CBTp on primary outcome of 0.372, an effect size that decreased to 0.223 when studies judged to be low in methodological rigor were excluded. Interestingly, of the 18 studies included in the Wykes et al. (2008) meta-analysis of CBTp interventions delivered in an individual format, all but 1 used global syndrome-focused outcome measures such as the Positive subscale of the Positive and Negative Syndrome Scale (P-PANSS; Kay, Fiszbein, & Opler, 1987), the Brief Psychiatric Rating Scale (BPRS; Overall & Donald, 1962), and Scale for the Assessment of Positive Symptoms (SAPS; Andreasen, 1984). With such widespread use of global measures of psychotic syndrome in the evaluation of the primary outcome in CBTp trials, it would appear that the assumed primary goal of these interventions is the amelioration of psychotic syndromes such as schizophrenia.

Recently, however, CBTp researchers prominent in the development of CBTp have argued strongly against the use of syndrome-focused outcome measures in CBTp treatment outcome studies, because in their view, the primary goal of CBTp is the reduction of emotional distress and behavioral disturbance rather than decreases in the severity of a psychotic "syndrome" (Birchwood & Trower, 2006). In their view, it has been a mistake to treat CBTp as though it was a "quasi-neuroleptic," evaluating the therapy using outcome measures designed for drug trials (Birchwood & Trower, 2006). They called for a "single-symptom" approach to the study of CBTp, consistent with the writings of authors such as Bentall, Jackson, and Pilgrim (1988) and Boyle (1990) who have for some time also argued for the abandonment of the construct of psychotic syndromes in psychology in favor of studying individual symptoms (Bentall, 1993). …

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