Academic journal article Journal of Cognitive Psychotherapy

What Are the Primary Goals of Cognitive Behavior Therapy for Psychosis? A Theoretical and Empirical Review

Academic journal article Journal of Cognitive Psychotherapy

What Are the Primary Goals of Cognitive Behavior Therapy for Psychosis? A Theoretical and Empirical Review

Article excerpt

Despite a rise in the popularity of cognitive behavior therapy for psychosis (CBTp) over the past 15 years, 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 (Jones, Hacker, Meaden, Cormac, & Irving, 2012; Wykes, Steel, Everitt, & Tarrier, 2008). However, for some time now, some authors prominent in the development of CBTp have argued the primary goals of CBTp not to be global syndrome reduction but the amelioration of emotional distress and behavioral disturbance in relation to individual psychotic symptoms (Birchwood & Trower, 2006). A review of the theoretical and empirical literature related to CBTp reveals broad support for this position. Implications and recommendations for research into the efficacy of CBTp are discussed.

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

Cognitive behavior therapy for psychosis (CBTp) has enjoyed endorsement by the United Kingdom's National Health Service as an evidence-based psychosocial treatment for schizophrenia since publishing its National Institute for Health and Clinical Excellence Guidelines approximately a decade ago (National Institute for Health and Care Excellence, 2002). The latest version of this guidance states that CBTp should be offered as an adjunct treatment to medication for "all people with schizophrenia. This can be started either during the acute phase or later, including in inpatient settings" (National Institute for Health and Care Excellence, 2009, p. 9). However, a recent Cochrane Review of CBTp versus other psychosocial treatments for schizophrenia has concluded that there is no evidence that CBTp is superior to any other psychosocial treatment on illness outcomes such as relapse rates, rehospitalization, or global measures of psychosis (Jones et al., 2012).

The Cochrane Review followed the earlier publication of a comprehensive meta-analysis of 32 CBTp studies by Wykes and colleagues in 2008. A notable part of the trial inclusion criteria for the meta-analysis was that all patients in the studies must have received CBTp as an adjunct to standard psychiatric care including appropriate medication. 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. These effect sizes might be called modest when compared to those reported elsewhere in the cognitive behavioral therapy (CBT) treatment outcome literature for other disorders. For example, a similar metaanalysis comparing exposure and ritual prevention and CBT for obsessive-compulsive disorder found mean effect sizes for both interventions in the range of 1.0 (Rosa-Alcázar, Sánchez-Meca, Gómez-Conesa, & Marín-Martínez, 2008). Similar results have been found in a meta-analysis of psychological interventions for posttraumatic stress disorder which found a mean effect size for behavior therapy of 1.27 (Van Etten & Taylor, 1998).

Of the 27 studies included in the Wykes et al. (2008) meta-analysis of CBTp interventions delivered in an individual format, 24 used syndrome-focused instruments as the primary measure of outcome, with the positive subscale of the Positive and Negative Syndrome Scale (PANSS; Kay, Fiszbein, & Opler, 1987) the most widely used along with the Brief Psychiatric Rating Scale (BPRS; Overall & Donald, 1962), and Scale for the Assessment of Positive Symptoms (SAPS; Andreasen, 1984). However, an important issue was raised but not addressed by Wykes et al. which may have implications for CBTp research. They point out that when we ask the question "Is CBTp effective?" we also need to ask "for what outcome?" This indicates an understanding that the effects of CBTp may vary depending on the outcome being explored. …

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