Cognitive and behavioural therapies for psychosis

The application of behavioural and cognitive therapies to psychotic symptoms and disorders has emerged as an evidence-based domain of treatment over the past two decades. We outline the current status of this field, and consider issues for implementation in Australasia.

What is CBTp?

Cognitive behavioural therapy for psychosis (CBTp) has become a collective term for a range of overlapping psychological therapies for people with psychotic disorders, based upon the application of behavioural and cognitive methods (Turkington et al., 2006). CBTp is usually delivered as a one-to-one therapy, typically in 16–20 sessions over about 6 months in treatment trials, and with a much wider range of duration in routine practice. It is most often used alongside medication to reduce distress and disability associated with persisting positive symptoms or to prevent relapse. Behavioural methods include conducting a personalised functional analysis of antecedents of, and existing responses to, distressing symptoms and using this to develop more effective means of coping. These are typically used in combination with cognitive restructuring methods, adapted from those used in cognitive therapy for depression and anxiety, to reduce the emotional impact of psychosis. Cognitive targets include distress-related aspects of delusional thinking, as well as broader beliefs about self and others which appear associated with the content or interpretation of psychotic experiences (see Morrison and Barratt, 2010).

Cognitive therapy methods require adaptations in working with people with psychosis who may hold markedly different explanatory models for their experiences from those of health professionals (Morrison and Barratt, 2010). Therapists often need to suspend their own disbelief in delusional material in order to engage the person in a workable dialogue about his or her experiences. Rather than trying to modify the person’s overall delusional system, therapists typically identify specific aspects of the person’s belief system associated with distress or disability, and foster modifications designed to reduce the impact of psychosis. For example, the belief that heard voices possess power to harm the person can be tested out and modified irrespective of whether the person has insight about the experience. Likewise, rather than directly questioning delusional material, therapists tend to focus on helping the person to consider alternative explanations for specific events and experiences interpreted in delusional terms. These may incorporate recognition of normal cognitive processes that maintain these experiences or associated distress such as hypervigilance, selective attention, jumping to conclusions and worry. Therapy may also include a collaborative formulation of the development of a person’s difficulties, often from a vulnerability-stress perspective, and incorporate relapse prevention elements such as self-monitoring of stressors and signs, and plans for coping and alerting others.

More recent developments in CBTp include tailoring methods to target key processes contributing to psychosis, such as probabilistic reasoning, biases to make external and personal attributions for negative events, and difficulties in social cognition (e.g. Moritz et al., 2011; Ross et al., 2011). Another area of development has been the application of new ‘third wave’ CBT methods, which have in common the fostering of a different relationship with inner experience, one that emphasises acceptance of experience and the skill of mindfulness (Morris et al., 2013).

The evidence base

A substantial number of randomised controlled trials of CBTp have been published, mostly focusing on persons with medication-resistant positive symptoms or first-episode presentations (National Collaborating Centre for Mental Health (NCCMH), 2009; Wykes et al., 2008). Benefits have been observed at up to 5 years’ follow up (Turkington et al., 2008). A meta-analysis of 34 trials (Wykes et al., 2008) found significant effects on positive, negative and mood symptoms, on severity of target symptoms and on social functioning. Another meta-analysis indentified a 26% reduction in readmission up to 18 months following CBTp relative to treatment as usual (NCCMH, 2009). At a minimum, the evidence to date clearly supports the efficacy of CBTp over routine care alone. Although some have questioned whether CBTp is superior to comparison therapies (Lynch et al., 2010), no other individual psychological therapy applied to psychosis has an equivalent level of empirical support. In addition, a small number of trials of effectiveness in routine practice (e.g. Lincoln et al., 2012) on balance demonstrate that the therapy can retain reasonable treatment effects in more routine implementation.

Whilst this evidence base is established, the effect sizes have been modest. In part this may be attributable to methodological issues, particularly the heterogeneity of outcomes arising from an individualised therapy and the insensitivity of broad symptom measures when applied to primary outcomes such as symptom-related distress. Nonetheless, like all established treatments for schizophrenia, CBTp works for some but not for all.

Dissemination and practice

The current status of evidence readily justifies tagging CBTp as an efficacious treatment. Not only does the now ageing Royal Australian and New Zealand College of Psychiatrists (2005) clinical practice guidelines for schizophrenia recommend it, but so too does the most recent Patient Outcomes Research Team (PORT) guideline from the USA (Dixon et al., 2010) and the UK Government’s National Institute for Health and Clinical Excellence (NICE) guidance for schizophrenia (NCCMH, 2009), arguably the most rigorous guideline. Given the multiple impairments and pervasive impact of the phenomenon of psychotic disorders, and the limitations to the effectiveness of all known treatments, the firm establishment of CBTp as an option is both impressive and useful.

The NICE guidelines have been influential in determining routine practice in the UK National Health Service, where CBTp is now extensively implemented. However, the UK is an exception which has benefited from its leading role in the development of CBTp and, whilst there are reports of CBTp implementation efforts in many other countries, the extent of dissemination into routine practice varies markedly across the globe. For example, CBTp has only relatively recently been the focus of training and implementation at some key centres in the USA, and has limited availability there (Turkington et al., 2006). There are currently no data on its implementation in Australia and New Zealand, though some self-report data from participants in the 2010 Second Australian National Survey of Psychosis is expected. Nonetheless, whilst there is some availability in public mental health services (e.g. Farhall and Cotton, 2002) and specialist clinics (e.g. Thomas et al., 2011), in the experience of the authors, the NICE guideline recommendation that CBT be routinely offered to all people with schizophrenia-related disorders (NCCMH, 2009) seems a long way off. Furthermore, whilst a few private psychologist practitioners offer CBTp, there appears to be very little delivery outside specialist mental health services.

Future directions

So, given that a decade has elapsed since first recommendation by a clinical practice guideline, what is keeping CBTp, in its current form, from being routinely implemented? We contend that there are critical gaps in workforce training, in the balance of evidence-based treatments offered and in sensible workforce utilisation.

As a specialist adaptation of CBT, a degree of specific training and supervised practice is essential, yet CBTp is not a mandatory part of any mental health professional training in Australia. A further barrier to routine implementation is that public mental health provision in Australia is not organised to make evidence-based psychological interventions a core part of mental health delivery – crisis intervention, pharmacological treatment and case management are considered core, with psychological therapies, regardless of evidence for efficacy, treated as adjuncts. In addition, workforce utilisation tends to reflect such priorities, with limited clinician time devoted to formal psychological therapy, even by those most skilled. For example, whilst there is variability around the country, local enquiries indicated that nine of metropolitan Melbourne’s 13 area mental health services employ clinical psychologists in their continuing care teams primarily as case managers.

What can be done about these barriers? CBTp is a complex intervention which demands both advanced skills in general cognitive behavioural therapy and familiarity with psychosis. An Australian trial of effectiveness in routine care when delivered by local psychologists with minimal specialist training found only weak benefits over treatment as usual (Farhall et al., 2009), suggesting that a level of training closer to the 10 days provided by Turkington et al. (2002) for psychiatric nurses may be required for more effective dissemination, especially when core CBT skills are not well established. Although uncommon in this country, the potential route to competence via professional development workshops or workplace training plus supervision for practitioners who already have generalist CBT skills is realistic, and one key direction.

The contentious area of relative priority of psychological treatments is beyond the scope of this paper, other than to point out an opportunity. The imminent release of the National Recovery Framework for mental health services should prompt both providers and funders to reconsider the role and priority of the range of possible interventions in recovery-oriented mental health care, perhaps contributing to a better balance and to a consideration of how their implementation may be supported. Recovery frameworks conceptualise recovery from serious mental illness as an individual’s unique journey, with the consumer in the driver’s seat and clinical and social services contributing resources towards a goal of social inclusion and living well despite illness. CBTp certainly provides methods that assist consumers in understanding and self-managing illness, integral to recovery, and CBTp methods may assist in the process of self-redefinition, often highlighted as important in personal recovery (Andresen et al., 2003). However, domains of personal recovery have yet to be measured as outcomes of CBTp, and there is work to do in developing a more recovery-aligned version of CBTp.

Addressing public mental health workforce limitations through referral to independently practising psychological treatment providers, may help to a degree, but will not solve the problem: provision of therapy to people with severe mental illness has not been a traditional domain for these providers, and is not well suited to the limited psychological treatment sessions available under Medicare. The introduction of new ATAPS (Access to Allied Psychological Services) Medicare items for people with severe mental illness represents a potential means of increasing access if implementation prioritises this and other evidence-based treatments. Similarly, supporting non-governmental organisation (NGO) mental health providers to do this work is plausible, but its clinical frame means a change in scope for their service philosophy, and support systems would be required.

Perhaps more importantly, a largely neglected issue is that the complexity of CBTp in its current form as a 16- session-plus, specialist-clinician-delivered, stand-alone therapy limits its widespread dissemination. If the fit of CBTp with the current service system is relatively poor, and the system slow to change, it may be that the therapy can be modified to more explicitly integrate with routine practice and workforce capabilities. To this end, an important area of development is to consider low-intensity versions of CBTp. As a response to the dilemma of delivering broad access to therapies when full formal delivery is in short supply, low-intensity variants of CBT for high-prevalence disorders have become an important component of delivery in both Australia (focused psychological strategies under Medicare) and overseas (e.g. stepped care models under the UK’s Improving Access to Psychological Therapy). Traditionally, CBTp has been difficult to distil into a simplified format; hence, as yet, there are no validated low-intensity versions. However, we believe there is the possibility to more widely disseminate potentially effective elements (e.g. coping enhancement, relapse prevention), including some of the contemporary developments in CBTp (e.g. reasoning skills training, mindfulness skills) and existing low-intensity interventions for comorbid anxiety and depression (e.g. graded exposure, behavioural activation; for a recent pilot study, see Waller et al., 2013). Development of briefer, focused and stand-alone components, if validated, may enable a broader workforce, including NGO workers, peers and carers, to bring CBT technology to a much greater proportion of those who might benefit.

Conclusions

In summary, CBTp is internationally accepted as an evidence-based set of treatments, but access to such therapy outside the UK is poor. Given its ability to make a meaningful difference to the lives of many people living with schizophrenia, systematic implementation in service systems in Australia and New Zealand should be a priority. This requires parallel approaches of training more experienced CBT practitioners in working with psychosis, enhancing the consistency of CBTp with recovery frameworks and developing and trialling low-intensity interventions that can be utilised across the mental health workforce.